Provider Network Operations Analyst

Amerihealth Caritas•,

9d•Hybrid

About The Position

This position reports to the Manager, Provider Reimbursement and is responsible for facilitating and investigating cross-departmental issue resolution as it relates to provider claim reimbursement. The primary purpose of this role is to maintain current provider data and provider reimbursement setup, and to address provider and state inquiries related to claim payment issues.

Requirements

2+ years of claims analysis experience in a healthcare environment.
Claims processing and provider data maintenance knowledge required.
Understanding of and experience with healthcare claims payment configuration processes/systems and their relevance and impact on network operations required.
Strong proficiency in Microsoft Excel, Access, Word, MS Office, Pivot Charts, and analytics.

Nice To Haves

Associate’s degree preferred.
Ability to focus on both technology and business issues, as well as communicate effectively with technology and business stakeholders.
1 to 2 years of managed care or related experience preferred.
1 to 2 years of Medicaid experience preferred.
Billing and coding experience is a plus.
Facets (Claims)
Lift
Ambient (Configuration, Billing, and Coding)

Responsibilities

Develop pricing and agreements for provider reimbursement setup.
Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched, and resolved within established SLA timeframes.
Serve as the subject matter expert in state-specific health reimbursement rules and provider billing requirements, and act as a liaison to the Enterprise Operations Configuration Department.
Maintain a current working knowledge of processing rules, contractual guidelines, state/Plan policies, and operational procedures to effectively provide technical expertise and guidance on business rules.
Participate in encounter rejection reconciliation activities.
Analyze provider reimbursement and update codes and fee schedules to ensure accurate provider reimbursement.
Participate in Provider Reimbursement medical policy and edit reviews.
Request and run queries to identify root causes of claim denials, incorrect payments, and claims that are not correctly submitted for payment. Highlight findings through weekly denial reports.
Act as a resource to other departments by developing and managing work plans that document the status of key relationship issues and action items for high-profile providers.
Ensure 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 systems for operational issues, progress, and status.
Perform other related duties and projects as assigned.