Provider Network Operations Analyst Sr

Amerihealth Caritas Health Plan•Charleston, SC

33d•Remote

About The Position

The primary purpose of the job is to be responsible for the maintaining current provider data and provider reimbursement set up, and to address provider/state inquiries as it relates to claim payment issues. Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up. Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched and resolved within established SLA timeframes. Serves as the subject matter expert in State specific health reimbursement rules and provider billing requirements and as liaison to the Enterprise Operations Configuration Department. Maintain a current working knowledge of processing rules, contractual guidelines, state/Plan policy and operational procedures to effectively provide technical expertise and business rules. Participate in encounter rejection reconciliation activities. Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers. Participate in Provider Reimbursement medical policy and edit reviews. Requests/runs queries to identify root causes of claim denials, incorrect payments and claims that are not correctly submitted for payment. Act as the resource to other departments by developing and managing work plans which document the status of key relationship issues and action items for high profile providers. Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits. Validate potential recovery claim project activities. Maintain tracking system of operational issues, progress, and status. Performs other related duties and projects as assigned.

Requirements

High School Diploma/GED required
American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC) required
Required ability to focus on technical claims processing and Provider data maintenance knowledge
Required understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations
1 to 2 years managed care or related experience preferred
1 to 2 years Medicaid experience preferred
2 to 5 years of claims analysis experience in a healthcare environment preferred
Healthcare billing and coding experience required
Strong with MicroSoft Office Suite (Excel, Word, Access, PowerPoint) preferred
Critical thinking and root cause analysis skills required

Nice To Haves

Associate's Degree or equivalent education and experience preferred
1 to 2 years managed care or related experience preferred
1 to 2 years Medicaid experience preferred
2 to 5 years of claims analysis experience in a healthcare environment preferred
Strong with MicroSoft Office Suite (Excel, Word, Access, PowerPoint) preferred

Responsibilities

Maintaining current provider data and provider reimbursement set up
Address provider/state inquiries as it relates to claim payment issues
Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up
Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched and resolved within established SLA timeframes
Serves as the subject matter expert in State specific health reimbursement rules and provider billing requirements and as liaison to the Enterprise Operations Configuration Department
Maintain a current working knowledge of processing rules, contractual guidelines, state/Plan policy and operational procedures to effectively provide technical expertise and business rules
Participate in encounter rejection reconciliation activities
Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers
Participate in Provider Reimbursement medical policy and edit reviews
Requests/runs queries to identify root causes of claim denials, incorrect payments and claims that are not correctly submitted for payment
Act as the resource to other departments by developing and managing work plans which document the status of key relationship issues and action items for high profile providers
Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits
Validate potential recovery claim project activities
Maintain tracking system of operational issues, progress, and status
Performs other related duties and projects as assigned