Note: The job is a remote job and is open to candidates in USA. Corewell Health is a nationally recognized health system committed to delivering personalized health care. The Provider Operations Associate Analyst is responsible for analyzing provider operations data, resolving issues related to provider enrollment, and ensuring compliance with healthcare standards.
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, determining accurate payment of claims, and ensure annual payment of multi-million dollar access fees are paid accurately and timely to all national networks
- Departmental subject matter expert who determines root cause and takes necessary action to resolve. Ensure effective communication of resolution to appropriate next level. Acts as a mentor to Provider Operations Associate Analyst
Skills
- High School Diploma or equivalent
- 2 years of relevant experience in healthcare, insurance, managed care and/or comparable industry or related field
- 1 year of relevant experience in an operations area
- Associate's degree or equivalent
- Bachelor's degree
- 1 year of relevant 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
- 1 year of relevant experience with provider configuration, credentialing, claims and/or comparable systems
- 1 year of relevant 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
- CRT-Professional Medical Services Management, Certified (CPMSM)
Benefits
- Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here
- 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
- Eligibility for benefits is determined by employment type and status
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