This site uses cookies. To find out more, see our Cookies Policy
View All Jobs at PrideStaff

Provider Network Specialist in Nashville, TN at PrideStaff

Date Posted: 1/8/2019

Job Snapshot

  • Employee Type:
  • Location:
    Nashville, TN
  • Job Type:
  • Experience:
    At least 5 year(s)
  • Date Posted:

Job Description

Provider Network Specialist!

Essential Functions of Job:

  • Create and maintain a contract/demographic library and cross reference for all networks.

  • Interact with Provider Relations, Account Management and EBD Claim Units to develop new networks and research any network discrepancies and/or inquiries.

  • Access provider data stored on thenetwork and reformat files as necessary using Microsoft Excel and/or Microsoft Access to format into an appropriate layout.

  • Work with Tech Services to load provider data from external sources.  Tasks include:

    • Create and maintain load translation table for Cactus extracts of provider data (HSB Network) on the claims processing system.

    • Prepare load documents (specialty tables, provider type tables, fee schedules  & network ID tables)

    • Prepare load instructions for Tech Services to use when programming for each PPO vendor.

  • Download select provider data loads from PPO vendor websites & load on the shared drive for use by Provider Network, Provider Maintenance, Provider Relations, Account  Managers & Tech Services.

  • Build and load physician and hospital fee schedules and header records for networks priced online.  Maintain fee matrix.

  • Maintain documentation on all loads.

    • Review changes in layouts for incoming provider data from the PPO vendors.  Advise Tech Services of changes needed in programming.

  • Verify fee schedule ID’s on incoming data have corresponding fee schedules loaded on the claims systems.  If not, requests those fees to be sent from the source to Provider Network for loading.

  • Develop and track receipt of network information, identifying when a network load has not been received when expected.

  • Perform QA and identify errors on the provider loads, working with Tech Services as needed to correct programming and/or report bad data errors back to the respective PPO vendor.  Note:  Post Production QA should equal approximately 10% of each load.

  • Provide/develop QA reporting to include monthly reporting of loads, schedules reviewed, issues found, resolution, and any trending.

  • Perform periodic audits on all network loaded and provide/develop reporting.

  • Maintain a log of all auto-pricing contracts, the ticket number, and submitted/completed date.

  • Attend all new business implementation meetings to document and assist in new or existing network development.

  • Manage the electronic transmittal of claims data between company and a new vendor to include testing, crosswalk logic, and weekly monitoring.

  • Ability to report to the office


  • High school diploma or equivalent

  • Effective organizational and prioritization skills

  • Excellent oral and written communication skills

  • Intermediate/Advance knowledge of Microsoft Office applications (Word, Excel, Outlook, Access)

  • Ability to work in a fast paced multi-tasking environment

  • Strong interpersonal skill with ability to function as a positive team member

  • Ability to quickly grasp new software, experience in computer operations/programming a plus

  • Logical, analytical approach to understanding of medical, dental, and vision benefits, claims processing, benefit interpretation and PPO network relationships desired

  • Knowledge of Healthaxis claims system desired

  • 5 or more years of health claims administration experience preferred.