Job Detail

We are seeking a Medical Claims Terms and Conditions Specialist to join a national Managed Services Organization (MSO) that ensure timely and accurate processing of medical claims. This MSO provides quality medical management support to clients, such as medical groups and Independent Physician Groups (IPAs).

The Terms and Conditions Specialist will establish provider contracting arrangements or benefits administration data elements in the existing application and other platform applications. Configuration will support the accurate & timely payment of claims. Terms and Conditions Specialist will test new releases, make enhancement recommendations, and evaluates contracts for configuration

The Specialist should clearly understand the products and healthcare benefits services offered to customers, including cost share, limits and regulatory rules and guidelines.

In this role, you will:

• Configure provider contracts, Fee Schedule updates and other documents.
• Load new contracts into EZ-CAP and monitor updates
• Test and audit claims payment accuracy against contract information
• Consult partners to consult on interpretation & configuration of contract terms.
• Highly knowledge understanding of EZ_CAP rules relative to claims payment.
• Develop configuration testing & validate accuracy of data loaded.
• Coordinate research & resolution of debarred & sanctioned providers.
• Communicated required system updates to Provider Contracting & Claims operations.
• Add details into EZ-CAP. Verify W-9, NPI, Taxonomy codes, class codes, & Specialty codes.

For this job, you need:

• 3+ years of health care claims processing, credentialing, contracting or utilization management experience required.
• 3+ years Medicare, Commercial & Medi-Cal processing, (Facility and Professional components).
• Intermediate proficiency with MS Word and Excel
• Associate's degree (A. A.) or equivalent

Benefits:

• Insurance benefits including medical, dental, vision & PPO are offered 100% for employee. Employee pays for dependents
• Employer offers paid time off (PTO) of 12 days, plus 3 bonus days and also 401k match.

Job Type: Full-time

Pay: $23.00 - $26.00 per hour

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• medical claims examiner: 1 year (Preferred)
• Medicare: 1 year (Preferred)
• medi-cal: 1 year (Preferred)

Work Location: One location