Provider Network Operations Analyst

This position reports to the Manager, Provider Reimbursement and is responsible for facilitating and investigating cross-departmental issue resolution as it relates to provider claim reimbursement. The primary purpose of this role is to maintain current provider data and provider reimbursement setup, and to address provider and state inquiries related to claim payment issues., * Develop pricing and agreements for provider reimbursement setup.

• Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched, and resolved within established SLA timeframes.
• Serve as the subject matter expert in state-specific health reimbursement rules and provider billing requirements, and act as a liaison to the Enterprise Operations Configuration Department.
• Maintain a current working knowledge of processing rules, contractual guidelines, state/Plan policies, and operational procedures to effectively provide technical expertise and guidance on business rules.
• Participate in encounter rejection reconciliation activities.
• Analyze provider reimbursement and update codes and fee schedules to ensure accurate provider reimbursement.
• Participate in Provider Reimbursement medical policy and edit reviews.
• Request and run queries to identify root causes of claim denials, incorrect payments, and claims that are not correctly submitted for payment. Highlight findings through weekly denial reports.
• Act as a 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.
• Ensure 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 systems for operational issues, progress, and status.
• Perform other related duties and projects as assigned.

• Associate’s degree preferred.
• Ability to focus on both technology and business issues, as well as communicate effectively with technology and business stakeholders.
• 2+ years of claims analysis experience in a healthcare environment.
• 1 to 2 years of managed care or related experience preferred.
• 1 to 2 years of Medicaid experience preferred.
• Claims processing and provider data maintenance knowledge required.
• Understanding of and experience with healthcare claims payment configuration processes/systems and their relevance and impact on network operations required.
• Billing and coding experience is a plus.
• Strong proficiency in Microsoft Excel, Access, Word, MS Office, Pivot Charts, and analytics.

Preferred Healthcare Systems Experience:

• Facets (Claims)
• Lift
• Ambient (Configuration, Billing, and Coding)

Pulled from the full job description

• Tuition reimbursement
• 401(k)
• Health insurance
• Paid time off
• Paid holidays, Our Comprehensive Benefits Package Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents starting Day 1, 401(k) retirement savings plan, tuition reimbursement, and more.

Why Join Us: Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation’s leaders in healthcare 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 are driven to make a difference, we want to hear from you.

About AmeriHealth Caritas Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at http://www.amerihealthcaritas.com

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