Senior Provider Network Operations Analyst

• Review/approve and audits 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

• Associate’s degree preferred, or equivalent combination of education and experience in a healthcare field.
• American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, CRC) or NHA (CBCS) certification required.
• 3 to 5 years of claims analysis experience in healthcare, managed care, or Medicaid environment preferred.
• Strong working knowledge of Microsoft Excel, Access, Word, and other MS Office tools; ability to work with pivot charts, Access databases, and data analytics.
• 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

Skills & Abilities:

• Ability to focus on technology and business issues, as well as communicate appropriately with both technology and business experts
• Superior organizational skills required
• Critical thinking skills
• Strong customer service skills
• Data and reporting analysis