Role Overview: The Senior Provider Network Operations Analyst responsible for maintaining current provider data and provider reimbursement setup, and to address provider and state inquiries as they relate to claim payment issues.
Work Arrangement:- This role is fully remote, and the associate must be able to work Eastern Standard Time (EST) hours.
- Candidates must have access to reliable high-speed internet (minimum 50 Mbps download / 5 Mbps upload).
- Associates in locations where required may be eligible for internet reimbursement based on applicable regulations.
Responsibilities:- Review/approve and audits 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:- Associate's degree preferred, or equivalent combination of education and experience in a healthcare field.
- American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, CRC) or NHA (CBCS) certification required.
- 3 to 5 years of claims analysis experience in healthcare, managed care, or Medicaid environment preferred.
- Strong working knowledge of Microsoft Excel, Access, Word, and other MS Office tools; ability to work with pivot charts, Access databases, and data analytics.
- 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
Skills & Abilities:- Ability to focus on technology and business issues, as well as communicate appropriately with both technology and business experts
- Superior organizational skills required
- Critical thinking skills
- Strong customer service skills
- Data and reporting analysis
