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 and will require the associate to work during Central/Eastern Standard Time (CST/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, analyze, and validate provider reimbursement and claim configuration requests in alignment with regulatory and contractual requirements.
- Review/approve and audit Payment Integrity (PI) vendor and internal prospective and retrospective edits/projects/recoveries
- User Acceptance Testing (UAT)/Client Review & audit
- Analyze Facets claims edit configuration requests to include intake and review of requests, impact assessment, and submission to Enterprise Operations.
- Encounter error reconciliation, representation, oversight, and management, including identification and initiation of claim or provider changes necessary to mitigate/prevent future errors
- Manage and resolve state complaints and escalated provider issues
- State policy and contract amendment changes analysis and management
- 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
- Manage internal and vendor reimbursement policies; identify trends for cost containment changes and initiatives
- Single-case agreement management/ownership, including letter development and coordination with Provider Network Management (PNM)
- Serves as the subject matter expert in state-specific 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
