Provider Network Operations Analyst Sr

Responsibilities:

The primary purpose of the job is to be responsible for the maintaining current provider data and provider reimbursement set up, and to address provider/state inquiries as it relates to claim payment issues.  

• Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up.
• 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 effectively provide technical expertise and business rules.
• Participate in encounter rejection reconciliation activities.
• Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers.
• Participate 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 which 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 tracking system of operational issues, progress, and status.
• Performs other related duties and projects as assigned.

Work Arrangement: 

100% Remote, work from home position.  Must reside in South Carolina or within driving distance to Charleston, SC office. 

Education/Experience:  

• High School Diploma/GED required.
• American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC) required. 
• Associate’s Degree or equivalent education and experience preferred.
• Required ability to focus on technical 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.
• 1 to 2 years managed care or related experience preferred.
• 1 to 2 years Medicaid experience preferred.
• 2 to 5 years of claims analysis experience in a healthcare environment preferred.
• Healthcare billing and coding experience required.
• Strong with MicroSoft Office Suite (Excel, Word, Access, PowerPoint) preferred.
• Critical thinking and root cause analysis skills required.

Other:

• Certified Professional Coder (CPC) is a requirement. 

   

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to hear you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.