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Provider Network Specialist 


PeakTPA provides services that optimize your organization's financial management and fulfill regulatory requirements for health plan functions. Our expertise in health plan management, particularly in PACE, means you can focus on delivering high-quality care to your participants.

Summary: Under the supervision of the Client Service Manager and Provider Network Supervisor, the Provider Network Specialist is responsible for creating provider records in the claims processing system and linking records to the appropriate fee schedule. This position is also responsible for analyzing and interpreting provider contracts to ensure accurate reimbursement.

May be on-site or remote if internet requirements, and other specific requirements, are met.

Essential Functions:

  • Creates provider and vendor records in claims processing system
  • Builds and maintains fee schedules based on submitted provider contracts
  • Assigns fee schedules to appropriate provider and vendor records
  • Effectively analyzes and interprets provider contracts
  • Manages pended claims that require additional contractual review

Additional Functions:

  • Assists with special projects, as requested
  • Communicates clearly and concisely, with sensitivity to the needs of others
  • Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
  • Maintains courteous, helpful and professional behavior on the job
  • Establishes and maintains effective working relationships with co-workers
  • Ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards
  • Follows all Policies and Procedures and HIPAA regulations
  • Maintains a safe working environment

Supervisory Responsibility: None

Travel: Minimal travel, less than 10%, expected for this position

Position Requirements

Knowledge, Skills and Abilities:

  • Educational requirements include a High School Diploma or equivalent. Three years of professional work experience in a Health Plan Management setting is preferred
  • Extensive knowledge of provider contracts, fee schedules and payment methodologies is preferred
  • Knowledge of medical terminology
  • Knowledge of and/or experience processing medical claims is preferred
  • Knowledge and experience using current computer technology, and a strong knowledge of Excel and Microsoft Word.
  • Skilled in establishing and maintaining effective working relationships with clients, and staff at all levels
  • Skilled in data analysis and problem solving using defined methodologies
  • Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency
  • Ability to work independently with minimal supervision
  • Ability to have superior attendance to fulfill all position functions
  • Ability to independently follow through on projects
  • Ability to communicate professionally, clearly and effectively, verbally and in writing
  • Ability to prioritize effectively
  • Ability to consistently multitask

Physical Demands & Requirements:

  • Communicate by way of the telephone with participants, customers, vendors and staff
  • Operate a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
  • Remain stationary for extended periods of time
  • Occasionally exert up to 20 pounds of force to lift, carry, push, pull or move objects
  • Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
  • Occasional reaching to retrieve shelved items
  • Occasional bending/stooping

Work Environment:

  • This job operates in a professional office environment with a conversational noise level.
  • No substantial exposure to adverse environmental conditions is expected.
  • Moderate pressure to meet scheduled appointments and deadlines
  • Potential for occasional verbal aggression by clients and vendors
Full-Time/Part-Time Full-Time  
Shift -not applicable-  
Position Provider Network Specialist  
Post Internal Days 0  
Number of Openings 1  
Location Peak Health Plan Management- St Louis, MO  
About the Organization  
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.  
Cell None Specified 

HoursPerWk None Specified 

supervisorUID None Specified 

This position is currently not accepting applications.

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