Role Overview: 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.
Work Arrangement:- Remote - This position is fully remote; the associate must be located in Michigan (MI and attend monthly meetings as needed in Southfield, MI.
- Requires reliable high-speed internet (minimum 50 Mbps download / 5 Mbps upload)
- Internet reimbursement may be available where required by law or contract
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
Education & Experience:- American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, CRC) or NHA (CBCS) certification required.
- 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.
- 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.
Skills & Abilities:- Ability to focus on technology and business issues, as well as communicate appropriately with both technology and business experts
- Strong analytic problem-solving skills
- Superior organizational skills required
- Critical thinking skills
- Strong customer service skills
- Data and reporting analysis
