Senior Provider Network Operations Analyst

Amerihealth Caritas•Southfield, MI

5d•Remote

About The Position

The Senior Provider Network Operations Analyst serves as a subject matter expert within Provider Network Operations and is responsible for operational accuracy, regulatory compliance, claims configuration, provider data, and related network operations. This position is fully remote and requires the associate to be located in Michigan. Reliable high-speed internet is necessary, and internet reimbursement may be available where required by law or contract. The role involves reviewing and auditing payment integrity initiatives, conducting user acceptance testing for provider data and claims configuration, managing encounter error reconciliation, and handling state complaints and policy changes. The analyst will also manage medical policy changes, analyze state communications, oversee business process outsourcing tools, and manage single-case agreements. A key aspect of the role is serving as a subject matter expert on state-specific health reimbursement rules and provider billing requirements, acting as a liaison to the Enterprise Operations Configuration Department. Maintaining current knowledge of processing rules, contractual guidelines, and operational procedures is essential for providing technical expertise. The position also involves developing and managing work plans for high-profile providers and performing other assigned duties.

Requirements

American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, CRC) or NHA (CBCS) certification required.
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 required
Strong working knowledge of Microsoft Excel, Access, Word, and other MS Office tools; ability to work with pivot charts, Access databases, and data analytics.

Nice To Haves

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

Responsibilities

Review/approve and audit Payment Integrity (PI) vendor and internal prospective and retrospective edits/projects/recoveries.
User Acceptance Testing (UAT)/Client Review & audit (provider data, Appian Advanced Group ID (AGID) configuration, and set-up concentration) reviews requests prior to initial submission to Enterprise Operations (EO) and claims post-production.
Facets claims edit configuration concentration (Appian) – intake, review, impact assessment, and initial submission; UAT reviews requests prior to initial submission to EO and claims post-production.
Encounter error reconciliation representation, oversight, and management – including identification and initiation of claim or provider changes necessary to mitigate/prevent future errors.
Management and resolution of state complaints.
State policy and contract amendment changes analysis and management.
Internal or vendor medical policy or Health Value Optimization (HVO) edit changes and initiatives.
Monitor and review state communications and changes, lead initial analysis/determination of action, provide direction on work request submissions to level I analysts, and test/audit subsequent changes.
Business Process Outsourcing (BPO) and/or other intake/workflow tool management.
Single-case agreement management/ownership, including letter development and coordination with Provider Network Management (PNM).
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.
Acts 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.
Performs other related duties and projects as assigned