PeakTPA provides services that optimize your organization’s financial management and fulfill regulatory requirements for health plan functions. Our expertise in health plan management, particularly in PACE, means you can focus on delivering high-quality care to your participants.
Summary: Under the supervision of the Provider Network Supervisor, the Provider Network Specialist is responsible for creating provider records in the claims processing system and linking records to the appropriate fee schedule. This position is also responsible for analyzing and interpreting provider contracts to ensure accurate reimbursement.
Creates provider and vendor records in claims processing system
Builds and maintains fee schedules based on submitted provider contracts
Assigns fee schedules to appropriate provider and vendor records
Effectively analyzes and interprets provider contracts
Manages pended claims that require additional contractual review
Assists with special projects, as requested
Communicates clearly and concisely, with sensitivity to the needs of others
Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
Maintains courteous, helpful and professional behavior on the job
Establishes and maintains effective working relationships with co-workers
Ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards
Follows all Policies and Procedures and HIPAA regulations
Maintains a safe working environment
Supervisory Responsibility: None
Travel: Minimal travel, less than 10%, expected for this position
Knowledge, Skills and Abilities:
Educational requirements include a High School Diploma or equivalent. Three years of professional claims processing experience in a Health Plan Management setting is preferred
Knowledge of provider contracts, fee schedules and payment methodologies
Knowledge of medical terminology
Knowledge of medical claims processing
Knowledge and experience using current computer technology, and a strong knowledge of Excel and Microsoft Word.
Skilled in establishing and maintaining effective working relationships with clients, and staff at all levels
Skilled in data analysis and problem solving using defined methodologies
Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency
Ability to work independently with minimal supervision
Ability to have superior attendance to fulfill all position functions
Ability to independently follow through on projects
Ability to communicate professionally, clearly and effectively, verbally and in writing
Ability to prioritize effectively
Ability to consistently multitask
Physical Demands & Requirements:
Communicate by way of the telephone with participants, customers, vendors and staff
Operate a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
Remain stationary for extended periods of time
Occasionally exert up to 20 pounds of force to lift, carry, push, pull or move objects
Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
Occasional reaching to retrieve shelved items
This job operates in a professional office environment, or home office environment, with a conversational noise level.
No substantial exposure to adverse environmental conditions is expected.
Moderate pressure to meet scheduled appointments and deadlines
Potential for occasional verbal aggression by clients and vendors
Tabula Rasa Healthcare
Why Work Here?TRHC provides patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize medication regimens. We improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. We deliver our solutions through a comprehensive suite of technology-enabled products and services for medication risk management and risk adjustment.
Growing company with casual environment, generous benefits and growth opportunities!