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; the associate must be located in Michigan (MI) and attend monthly meetings as needed in Southfield, MI.
• Requires reliable high-speed internet (minimum 50 Mbps download / 5 Mbps upload)
• Internet reimbursement may be available where required by law or contract

Responsibilities

• Review/approve and audit Payment Integrity (PI) vendor and internal prospective and retrospective edits/projects/recoveries.
• User Acceptance Testing (UAT)/Client Review & audit (provider data, Appian Advanced Group ID (AGID) configuration, and set-up concentration) reviews requests prior to initial submission to Enterprise Operations (EO) and claims post-production.
• Facets claims edit configuration concentration (Appian) – intake, review, impact assessment, and initial submission; UAT reviews requests prior to initial submission to EO and claims post-production.
• Encounter error reconciliation representation, oversight, and management – including identification and initiation of claim or provider changes necessary to mitigate/prevent future errors.
• Management and resolution of state complaints.
• State policy and contract amendment changes analysis and management.
• Internal or vendor medical policy or Health Value Optimization (HVO) edit changes and initiatives.
• 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.
• Business Process Outsourcing (BPO) and/or other intake/workflow tool management.
• Single-case agreement management/ownership, including letter development and coordination with Provider Network Management (PNM).
• Serves as the subject matter expert in state-specific health 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