Note: The job is a remote job and is open to candidates in USA. AmeriHealth Caritas is seeking a Senior Provider Network Operations Analyst to serve as a subject matter expert supporting provider network operations. The role focuses on reimbursement and claims configuration, regulatory compliance, provider data, encounter reconciliation, state requirements, vendor policies, and escalated provider issues in a remote work environment.
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
Skills
- * American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, CRC) or NHA (CBCS) certification required
- 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
- * 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
- * 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
- * Strong working knowledge of Microsoft Excel, Access, Word, and other MS Office tools; ability to work with pivot charts, Access databases, and data analytics
Benefits
- Fully remote work arrangement
- Associates in locations where required may be eligible for internet reimbursement based on applicable regulations
Company Overview
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