Senior provider network operations analyst

Role Overview:

The Senior Provider Network Operations Analyst serves as a subject matter expert within Provider Network Operations and is responsible for operational accuracy, regulatory compliance, claims configuration, provider data, and related network operations.

Work Arrangement:

Remote - This position is fully remote and will require the associate to work during Central/Eastern Standard Time (CST/EST) hours. Candidates must have access to reliable high-speed internet (minimum 50 Mbps download / 5 Mbps upload). Associates in locations where required may be eligible for internet reimbursement based on applicable regulations.

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.

Education & Experience:

• American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, CRC) or NHA (CBCS) certification required.
• 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.
• 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.
• Strong working knowledge of Microsoft Excel, Access, Word, and other MS Office tools; ability to work with pivot charts, Access databases, and data analytics.

Skills & Abilities:

• 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.