Configuration Specialist - Pricing
We exist for workers and their employers -- who are the backbone of our economy. That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills.
Summary of role:
The Configuration Specialist Pricing role is responsible for the accurate and timely configuration and maintenance of provider contract and pricing configurations within Centivo’s core systems. This role involves interpreting contract terms, setting up fee schedules, and ensuring compliance with regulatory and organizational standards to support timely and accurate claims adjudication and provider payments. Key responsibilities include collaborating with the Network Contracting and Provider Relations team, configuring pricing mechanisms and fee schedules, coordinating with business units and vendors during client implementations, and ensuring system interfaces meet client and operational needs.
Responsibilities Include:
Ability to read and interpret new and existing physician, facility and ancillary contracts.
Perform manual pricing based on accurate interpretation of contract language.
Configure and maintain provider contracts in the health plan’s database systems.
Interpret and apply contract terms, fee schedules, and reimbursement methodologies.
Skilled in interpreting and implementing both new and existing contract pricing configurations within the Centivo pricing platform, ensuring comprehensive client and claims administration aligned with product design and functionality, and conducting necessary test validations.
Identify contracts that are incompatible with Centivo’s pricing platform and collaborate with external pricing vendors to ensure accurate integration of these contracts into their systems as needed.
Collaborate with the Network Management, Provider Relations and Claims team when contracts are built or corrected to ensure updates are made in all systems pertaining to contracted providers.
When contract accuracy is in question, analyze claim impact reports to determine if claims are priced correctly.
Complete claim adjustments based on provider disputes, requests from internal departments and as determined by analyzing Claim Impact reports.
Complete configuration changes as identified, run, and evaluate claim adjustment reports within Centivo’s claim platform and supporting systems.
Perform unit and/or end user testing for new configuration, programming enhancements, new provider contracts, and software changes as necessary that affect claims adjudication rules.
Participate in special projects as needed and function as a liaison with specified user areas to define business requirements and processes for project deployment.
Provide technical support and training for other team members as needed.
Required Skills and Abilities:
Demonstrated ability to identify when platform limitations or capabilities require a contract to be sent to an external pricing vendor.
Ability to perform contract reviews to determine accuracy in configuration and correct as needed.
Ability to analyze claims for pricing accuracy against contract requirements.
Exemplary customer service skills demonstrated by researching and resolving issues that are configuration related in a timely and accurate manner.
Possess excellent analytical and problem-solving skills.
Ability to work independently and as part of a team.
Ability to multi-task and apply critical thinking skills.
Strong attention to detail and accuracy.
Enjoy working in a fast-paced environment managing multiple issues with pressure of production schedules and deadlines.
Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information form others, including but not limited to reimbursement policy standards.
Strong people skills, establishing rapport and working well with others.
Preferred Skills and Attributes:
3 years of experience in provider contract configuration, health plan claims process or a similar role preferred.
In-depth knowledge of all claim components that influence pricing, including the requirements for UB and HCFA forms.
Knowledge and experience in coding with Current Procedural Terminology (CPT), Healthcare Common Procedure Code System (HCPCS), International Classification of Diseases 10th Revision (ICD-10), Revenue and Diagnosis Related Groups (DRG), Current Dental Terminology (CDT), other relevant medical and industry-standard codes.
Proficient in professional and institutional claims adjudication.
Knowledge in health insurance benefit administration within a self-funded plan.
Preferred Qualifications:
The ideal candidate will have HealthRulesPayer (HRP) and HealthEdge Source (Source) experience.
Knowledge of TPA and self-funding processes and system contract configuration is preferred.
Advanced proficiency in Microsoft Office applications.
Education
High school diploma or GED; associate or bachelor’s degree preferred.
Work Location:
This position is remote.
Centivo Values:
Resilient – This is wicked hard. There is no easy button for healthcare affordability. Luckily, the mission makes it worth it and sustains us when things are tough. Being resilient ensures we don’t give up.
Uncommon - The status quo stinks so we had to go out and build something better. We know the healthcare system. It isn't working for members, employers, and providers. So we're building it from scratch, from the ground up. Our focus is on making things better for them while also improving clinical results - which is bold and uncommon.
Positive – We care about each other. It takes energy to do hard stuff, build something better and to be resilient and unconventional while doing it. Because of that, we make sure we give kudos freely and feedback with care. When our tank gets low, a team member is there to be a source of new energy. We celebrate together. We are supportive, generous, humble, and positive.
Who we are:
Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers. Employees also realize significant savings through our free primary care (including virtual), predictable copay and no-deductible benefit plan design. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies. For more information, visit centivo.com.
Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading healthcare and technology investors, including a recent round of investment from Morgan Health, a business unit of JPMorgan Chase & Co.