Note: The job is a remote job and is open to candidates in USA. Corewell Health is a health system committed to delivering personalized health care to patients, members, and communities. The Provider Operations Analyst Associate analyzes provider operations data, oversees provider enrollment information, resolves complex provider-related issues, and supports accurate claims processing, credentialing, reporting, and compliance.
Responsibilities
- Discerns, initiates, and maintains the complex provider enrollment information in both Evips and Facets systems accurately and timely to ensure the annual multi-million-dollar claims payout and the annual multi-million-dollar Physician Incentive Program settlement payout to provider’s is correct
- Performs analytics to determine provider to member primary care affiliation when providers move from locations. This involves, but not limited to, collaboration with physician groups to best relocate members to the appropriate primary care provider, collaboration with Priority Health member enrollment division, and Provider Network Performance division all to ensure that Priority Health members are receiving the right care with the right provider
- Performs analysis, and independent evaluation and ongoing monitoring of provider credentials (licensure, malpractice, etc.), as applicable, in order to meet Priority Health criteria, state, accreditation and CMS compliance requirements and high standards
- Ensures collection, storage and accuracy of product specific data for CMS service area expansion, network adequacy reporting and Medicaid Provider reporting. Performs gap analysis
- Manages and implements organizational operational efficiencies for the entire network of 82,000+ providers, provider groups, facilities, and national network providers, to resolve complex provider issue resolution
- Resolves complex issues that results from the entire PH eco system, i.e., medical authorization, provider contract setup, claims payment, finance, etc
- Manages the repricing of claims for PH national provider network (Cigna) including overall review of claims, denying claims, and determining accurate payment of claims
- Performs self-audits and participates in audit process. Based on the audit analysis, this role determines actions necessary to correct erroneous provider demographic and contractual data to positively affect accurate claims processing and payments
- Actively participates in safety initiatives and risk mitigating measures where appropriate and completes all position and unit safety related competencies and requirements on a timely basis
- Performs other duties as assigned
Skills
- Associate's Degree or equivalent
- 1 year of relevant experience in healthcare, insurance, managed care and/or comparable industry
- 1 year of relevant experience in an operations area
- Experience with accreditation and/or regulatory bodies like NCQA, CMS, MDCH, TJC, etc., standards related to credentialing and/or billing, and/or quality auditing requirements
- Experience with provider configuration, credentialing, claims and/or comparable systems
- Experience in running reports utilizing Access databases, Business Objects Report Writer, and/or comparable reporting tools
- CRT-Provider Credentialing Specialist, Certified (CPCS) - NAMSS National Association Medical Staff Services Or
- CRT-Professional Medical Services Management, Certified (CPMSM)
Benefits
- Comprehensive benefits package to meet your financial, health, and work/life balance goals.
- On-demand pay program powered by Payactiv
- Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
- Optional identity theft protection, home and auto insurance
- Traditional and Roth retirement options with service contribution and match savings
- From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do.
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