Provider Network Operations Analyst Senior - Remote Eligible

Provider Network Operations Analyst Senior

The Provider Network Operations Analyst Senior is to be responsible for maintaining current provider data and provider reimbursement set up, and to address provider/state inquiries related to claim payment issues.

Work Arrangement: Remote with required hours 8am-5pm Eastern Time

Responsibilities:

• Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up
• Ensures that provider payment issues submitted by Provider Network Management or any other source are validated, researched, and resolved within established SLA timeframes
• 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
• Maintains a current working knowledge of processing rules, contractual guidelines, state/Plan policy and operational procedures to effectively provide technical expertise and business rules
• Participates in encounter rejection reconciliation activities
• Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers
• Participates in Provider Reimbursement medical policy and edit reviews
• Requests/runs queries to identify root causes of claim denials, incorrect payments, and claims that are not correctly submitted for payment
• 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
• Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits
• Validates potential recovery claim project activities
• Maintains tracking system of operational issues, progress, and status
• Performs other related duties and projects as assigned

Education/Experience:

• Associate's Degree preferred.
• Required ability to focus on technical 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.
• AAPC Coding Certificate (CPC,COC,CIC,CRC) preferred
• 1-2 years managed care or related experience preferred; 1-2 years Medicaid experience preferred.
• 2+ years of claims analysis experience in a healthcare environment.
• Billing and coding experience required.
• Experience with Facets preferred
• Experience with Microsoft Excel required.
• Experience utilizing the following Microsoft tools: Access, Word, Office, Pivot Charts, Analytics
• Critical thinking and root cause analysis skills required.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, competitive pay, paid time off including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.