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Provider Network Specialist

Springfield, MA

Posted: 07/21/2023 Industry: Health Insurance Job Number: 34

Job Description

Job Summary: The ideal candidate for this position will have experience working in the health insurance industry and be familiar with PPO Network operations and applying them to practical daily operations. They should also be familiar with provider contracting, provider relations, provider billing, coding and appeals.

  • Research, respond (by phone and email) and track inquiries that come into the Provider Relations mailbox.
  • Re-price claims in LuminX system for all networks.
  • Add and maintain LuminX provider records for all school plans.
  • Call providers to obtain updates for Tax ID numbers and W9 forms.
  • Handle Electronic Data Interchange (EDI) claim rejections. Work with PPO networks to get pricing and apply manual re-pricing as needed.
  • Coordinate with cost-containment vendor on claim edits and audits, claim cancellations, and appeals.
  • Work with provider networks and vendors to resolve appeals: research and use analytical skills to evaluate facts and maintain tracking spreadsheet to monitor number of appeals.
  • Process and research issues with returned checks.
  • Participate in PPO Network and vendor quarterly oversight calls/meetings as needed.

Job Requirements

  • Associate’s degree in Health Administration, Business Administration, or an equivalent combination of education and work experience in related field.
  • 2-3 years’ experience in health insurance industry with focus on medical provider contracting, relations, and/or medical provider billing and coding.
  • Exemplary Customer service experience.
  • Excellent verbal and written communication skills.
  • Ability to work independently and as a member of the team.
  • Ability to maintain composure and diplomacy in negotiations and when under pressure or challenged.
  • Detail-oriented problem solver with excellent time management skills.
  • Proficiency with MS Office products to include Outlook, Excel, and Word.

Additional Information

  • Full time: Monday-Friday, 8am-5pm
  • Hybrid schedule

Meet Your Recruiter

Tanner Soos
Staffing Manager

Tanner joined the Pascoe team in July 2022 and is very excited for this new experience! He attends the Isenberg School of Management at the University of Massachusetts Amherst. In his free time, he loves to golf, run, and play music. He has been singing in a band for almost seven years and enjoys being on stage and meeting new people. Tanner still plays lacrosse and hockey, loves the Boston Bruins and always finds time to watch every game.

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