Note: The job is a remote job and is open to candidates in USA. AmeriHealth Caritas is a mission-driven health care organization providing managed care and related health care solutions. The Provider Network Operations Analyst facilitates and investigates provider claim reimbursement issues, maintains provider data and reimbursement setup, resolves payment inquiries, and supports accurate claims processing and operational reporting.
Responsibilities
- Develop pricing and agreements for provider reimbursement setup
- Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched, and resolved within established SLA timeframes
- Serve as the subject matter expert in state-specific health reimbursement rules and provider billing requirements, and act as a liaison to the Enterprise Operations Configuration Department
- Maintain a current working knowledge of processing rules, contractual guidelines, state/Plan policies, and operational procedures to effectively provide technical expertise and guidance on business rules
- Participate in encounter rejection reconciliation activities
- Analyze provider reimbursement and update codes and fee schedules to ensure accurate provider reimbursement
- Participate in Provider Reimbursement medical policy and edit reviews
- Request and run queries to identify root causes of claim denials, incorrect payments, and claims that are not correctly submitted for payment. Highlight findings through weekly denial reports
- Act as a resource to other departments by developing and managing work plans that document the status of key relationship issues and action items for high-profile providers
- Ensure ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits
- Validate potential recovery claim project activities
- Maintain tracking systems for operational issues, progress, and status
- Perform other related duties and projects as assigned
Skills
- High School Diploma or GED required
- Ability to focus on both technology and business issues, as well as communicate effectively with technology and business stakeholders
- Minimum of 2 years of claims analysis experience in a healthcare environment
- Minimum of 1 year of managed care experience
- Claims processing and provider data maintenance knowledge required
- Understanding of and experience with healthcare claims payment configuration processes/systems and their relevance and impact on network operations required
- Strong proficiency in Microsoft Excel, Access, Word, MS Office, Pivot Charts, and analytics
- Associate's Degree preferred
- Preferably within Medicaid
- Billing and coding experience is a plus
- Facets (Claims)
- Lift
Benefits
- Flexible work solutions including remote options and hybrid work schedules
- Paid time off including holidays and volunteer events
- Health insurance coverage for you and your dependents on Day 1
- 401(k)
- Tuition reimbursement
- Fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement of required high-speed internet service
Company Overview
Company H1B Sponsorship