What are the responsibilities and job description for the Senior Provider Network Operations Analyst position at AmeriHealth Caritas?
Role Overview: ;The Senior Provider Network Operations Analyst is responsible for maintaining current provider data and setting up provider reimbursement, as well as addressing provider and state inquiries related to claim payment issues.
Work Arrangement:
Work Arrangement:
- Hybrid – The associate must be in the office at least three (3) days per week at our Manchester, New Hampshire (NH) location.;
- Reviewing and auditing provider billing, claims processing and accuracy.
- Develops the Pricing Agreement Templates (PAT) for all provider reimbursement setups
- Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched, and resolved within established SLA timeframes.
- 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 provide technical expertise and business rules effectively
- Participating in encounter rejection reconciliation activities
- Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers
- Participating in Provider Reimbursement medical policy and edit reviews
- Requests/runs queries to identify root causes of claim denials, incorrect payments, and claims that are not correctly submitted for payment
- Act as the resource to other departments by developing and managing work plans that document the status of key relationship issues and action items for high-profile providers
- Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits
- Validate potential recovery claim project activities
- Maintain a tracking system of operational issues, progress, and status
- Performs other related duties and projects as assigned
- Associate’s degree preferred.
- 1 to 2 years of managed care or Medicare experience preferred
- 2 plus years of claims analysis experience in a healthcare environment
- American Academy of Professional Coders (AAPC) Certificate required
- Billing and coding experience is a plus ;
- Strong with Microsoft Excel, Access, and Word, including pivot charts and analytics.
- Critical thinking and root cause analysis skills are required.;
- Ability to focus on technical claims processing and Provider data maintenance knowledge.
- Understanding of and experience with healthcare claims payment configuration processes/systems and their relevance/impact on network operations.
- Technical knowledge with the ability to develop reports including data, averages and trending