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.

• High School Diploma or GED required; Associate’s Degree preferred.
• Ability to focus on both technology and business issues, as well as communicate effectively with technology and business stakeholders.
• Minimum of 2 years of claims analysis experience in a healthcare environment.
• Minimum of 1 year of managed care experience, preferably within Medicaid.
• 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

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.

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

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

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation’s 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’d like to hear from 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.