Senior Provider Network Operations Analyst

Amerihealth Caritas•Southfield, MI

3d•Remote

About The Position

The Senior Provider Network Operations Analyst serves as a subject matter expert within Provider Network Operations, responsible for operational accuracy, regulatory compliance, claims configuration, provider data, and related network operations. The role requires expertise in state-specific health reimbursement rules and provider billing requirements and serves as a liaison to the Enterprise Operations Configuration Department. 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 (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 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 analytical and 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 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 and audit of provider data, Appian Advanced Group ID configuration, and setup concentration requests before initial submission to Enterprise Operations, as well as claims post-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 claims post-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 state policy and contract amendment changes.
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 action determination, direct Level I analysts on work request submissions, and test or audit subsequent changes.
Manage Business Process Outsourcing and other intake or workflow tools.
Manage and own single-case agreements, including developing letters and coordinating with Provider Network Management.
Maintain current working knowledge of processing rules, contractual guidelines, state and Plan policies, and operational procedures to provide technical expertise and business rules.
Develop and manage work plans documenting the status of key relationship issues and action items for high-profile providers, and serve as a resource to other departments.
Perform other related duties and projects as assigned.