Provider Administration Analyst

To analyze, translate and implement all relative data related to provider contracting into the adjudication systems for purposes of proper claims adjudication, utilization management, reporting and provider directories.

  • Reviews and analyses executed provider contracts for accuracy, completeness, and administrability
    • Identifies non programmable contracts and returns to management for discussion.
    • Offers solutions both temporary and permanent to assist in contract management.
    • Identifies contracts missing required information and supporting documentation and returns to requester.
  • Enters acceptable provider contracts into the Provider File Maintenance module so that proper claims adjudication, utilization management, and provider directories can occur.
  • Reviews pended claims due to issues with providers and assists in the resolution of the provider edit.
  • Creates systemic rate schedules and attaches to entered provider contracts so that automated and proper claims pricing can occur as well as monthly capitation payments.
  • Coordinates provider contracts with the Provider Credentialing Department for purposes of ascertaining a provider’ credentialed status and effectiveness in the system upon monthly committee meetings.
  • Provides support to Provider Claims Custormer Service as needed.
  • Creates and maintains Provider Web Portal Accounts for contracted providers.
  • Maintains a broad knowledge of CMS, Medicaid and state regulations as it relates to provider administration.
  • Maintains a productive working relationship with all departments outside provider administration.
  • Maintains a broad knowledge of all systems and related modules that access the provider administration databases.
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Complies with and/or adheres to company HIPAA policies and procedures.
  • Ensures integrity of data entered into company systems and/or databases.
  • Compliance with all personnel policies and procedures.
  • Perform additional duties and related essential duties as assigned.

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Required Education and Experience:

  • Associates Degree (AS, AA) or three years related experience and/or training; or equivalent combination of education and experience.
  • Minimum 3 years’ experience in a medical office claims operation environment with increasing levels of responsibility in the area of Provider Administration.
  • Demonstrated knowledge of Provider Administration in a medical claims environment.

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