Provider Contracting Specialist

About the role

The Provider Contracting Specialist manages provider contracts, maintains provider relationships, and ensures compliance with applicable regulations and policies.

Responsibilities

• Ensure accurate and timely management of provider contracts, including pricing NSA claims, negotiating NSA requests, and responding to independent dispute resolutions.
• Foster strong working relationships with providers through effective communication, timely response to inquiries, and proactive resolution of issues.
• Adhere to HIPAA regulations, OMES policies, and other relevant statutes by protecting the privacy and confidentiality of program participants' information.
• Enter and review provider demographics accurately and timely, ensuring an accuracy rate of 97% or better based on audits.
• Handle incoming and outgoing calls, emails, and provider retention tasks while maintaining a customer service quality audit score of 85% or better.
• Other duties as assigned.

Requirements

• Knowledge of provider contracting, health insurance operations, reimbursement methodologies, claims processes, regulatory requirements, and provider database maintenance.
• Strong organizational, analytical, customer service, written and verbal communication, negotiation, and problem-solving skills.
• Ability to manage multiple priorities, maintain accurate and confidential information, interpret contract provisions and policies, and build effective relationships with providers and internal partners.

Key Competencies

• Ensures Accountability: Consistently meets accuracy, quality, and timeliness standards.
• Communicates Effectively: Provides clear, responsive, and professional communication.
• Manages Complexity: Evaluates detailed contractual, regulatory, reimbursement, and provider-related information to resolve issues and support effective network operations.

Education and/or Experience

• A bachelor’s degree and 2 years of experience in health insurance benefit administration or health care industry provider contracting.
• An equivalent combination of education and experience.

Preference Qualifications

• Knowledge of Medicare guidelines policies and procedures.
• Knowledge of provider licensing, certification, contractual issues, reimbursement, procedural coding, benefit coverage and liability requirements.
• Knowledge regarding these laws, regulations and procedures are critical to the management of an effective Provider Network.
• Knowledge of provider database maintenance, plan provisions, agency policies, provider types, credentials management, coding and reimbursement methods, claims payment process, and contract provisions/terminology.
• Strong organizational skills.
• Knowledge of large group network management and provider services to include provider enrollment and contracting, verbal and written communication skills, customer services and experience providing phone coverage, provider recruitment, training, response to member and provider inquiries, use of network database applications.
• Requires a detailed understanding of insurance plan provisions, terms, policies, provider types, credentials management, coding and reimbursement methods, claims payment processes, contract provisions and terminology.
• Knowledge of and ability to use Microsoft Office Applications.

Physical Demands and Work Environment

• Work is typically performed in an office setting with climate-controlled settings and exposure to moderate noise levels.
• In the course of performing job duties, employees are required to speak, stand, walk, and reach with their hands and arms.
• This position requires extended periods of sitting and daily use of computers and phones.
• Employees must be willing to complete all job-related travel associated with this position.

Benefits

• Generous state-paid benefit allowance to offset insurance premiums.
• A wide selection of insurance plans with no pre-existing condition exclusions.
• Flexible Spending Accounts for health care and dependent care.
• Retail Savings Plan with employer contributions.
• 11 paid holidays annually.
• 15 days of vacation and 15 days of sick leave in the first year.
• Longevity Bonus recognizing years of public service.
• Public Service Loan Forgiveness eligibility and tuition reimbursement.
• Wellness benefits, including an on-site gym and fitness center discounts.