Prov Net Ops Analyst Sr

Amerihealth Caritas•Southfield, MI

10d•Remote

About The Position

The Senior Provider Network Operations Analyst is 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 position is fully remote, but the associate must be located in Michigan and attend monthly meetings as needed in Southfield, Michigan. Reliable high-speed internet is required, with a minimum of 50 Mbps download and 5 Mbps upload. Internet reimbursement may be available where required by law or contract.

Requirements

American Academy of Professional Coders certification (CPC, COC, CIC, or CRC) or NHA CBCS certification is required.
Knowledge of claims processing and provider data maintenance is required.
Understanding of and experience with healthcare claims payment configuration processes and systems, and their relevance and impact on network operations, is required.
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 analytical problem-solving skills.
Superior organizational skills.
Critical-thinking skills.
Strong customer-service skills.
Data and reporting analysis skills.
Must be located in Michigan and have reliable high-speed internet with at least 50 Mbps download and 5 Mbps upload.

Nice To Haves

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

Responsibilities

Review, approve, and audit Payment Integrity vendor and internal prospective and retrospective edits, projects, and recoveries.
Conduct User Acceptance Testing and client-review audits involving provider data, Appian Advanced Group ID configuration, and setup concentration; review requests before initial submission to Enterprise Operations and review claims after production.
Manage Facets claims-edit configuration concentration in Appian, including intake, review, impact assessment, and initial submission; conduct UAT reviews before initial submission to Enterprise Operations and review claims after production.
Oversee and manage encounter error reconciliation, including identifying and initiating claim or provider changes needed to mitigate or prevent future errors.
Manage and resolve state complaints.
Analyze and manage changes to state policy and contract amendments.
Manage internal or vendor medical policy and Health Value Optimization edit changes and initiatives.
Monitor and review state communications and changes, lead initial analysis and determination of actions, direct Level I analysts on work request submissions, and test or audit subsequent changes.
Manage Business Process Outsourcing and/or other intake and workflow tools.
Own and manage single-case agreements, including developing letters and coordinating with Provider Network Management.
Serve as the subject matter expert in state-specific health 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.
Support other departments by developing and managing work plans that document the status of key relationship issues and action items for high-profile providers.
Perform other related duties and projects as assigned.