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