Senior Provider Network Operations Analyst

Amerihealth Caritas•,

2d•Remote

About The Position

The Senior Provider Network Operations Analyst serves as a subject matter expert within Provider Network Operations. The role is responsible for operational accuracy, regulatory compliance, claims configuration, provider data, and related network operations. This is a fully remote position requiring work during Central/Eastern Standard Time (CST/EST) hours. Candidates must have reliable high-speed internet with a minimum of 50 Mbps download and 5 Mbps upload. Associates in locations where required may be eligible for internet reimbursement based on applicable regulations.

Requirements

American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, or CRC) or NHA (CBCS) certification.
Knowledge of claims processing and provider data maintenance.
Understanding of and experience with healthcare claims payment configuration processes and systems and their relevance to and impact on network operations.
Strong working knowledge of Microsoft Excel, Access, Word, and other Microsoft Office tools, including the ability to work with pivot charts, Access databases, and data analytics.
Ability to focus on technology and business issues and communicate appropriately with technology and business experts.
Strong analytic problem-solving skills.
Superior organizational skills.
Critical thinking skills.
Strong customer service skills.
Data and reporting analysis skills.

Nice To Haves

Associate’s degree, or equivalent combination of education and experience in a healthcare field.
3 to 5 years of claims analysis experience in healthcare, managed care, or a Medicaid environment.

Responsibilities

Review, analyze, and validate provider reimbursement and claim configuration requests in alignment with regulatory and contractual requirements.
Review, approve, and audit Payment Integrity (PI) vendor and internal prospective and retrospective edits, projects, and recoveries.
Conduct User Acceptance Testing (UAT), client reviews, and audits.
Analyze Facets claims edit configuration requests, including intake and review, impact assessment, and submission to Enterprise Operations.
Reconcile, represent, oversee, and manage encounter errors, including identifying and initiating claim or provider changes needed to mitigate or prevent future errors.
Manage and resolve state complaints and escalated provider issues.
Analyze and manage state policy and contract amendment changes.
Monitor and review state communications and changes; lead initial analysis and determination of action; provide direction on work request submissions to Level I analysts; and test and audit subsequent changes.
Manage internal and vendor reimbursement policies and identify trends for cost-containment changes and initiatives.
Manage and own single-case agreements, including letter development and coordination with Provider Network Management (PNM).
Serve as the subject matter expert in state-specific reimbursement rules and provider billing requirements, and act as liaison to the Enterprise Operations Configuration Department.
Maintain current working knowledge of processing rules, contractual guidelines, state and Plan policy, and operational procedures to provide technical expertise and business rules.
Develop and manage work plans for other departments, documenting the status of key relationship issues and action items for high-profile providers.
Perform other related duties and projects as assigned.