Provider Network Operations Analyst

Freddie Mac; United States; Remote; USD 60,000 - 85,000; Full time

Job summary

A leading managed care organization is seeking a Provider Network Operations Analyst. The role involves managing provider data, ensuring accurate reimbursements, and analyzing claims issues. Ideal candidates will have relevant experience in claims analysis and managed care, contributing to improved healthcare outcomes across communities.

Benefits

Flexible work solutions including remote options

Competitive pay

Paid time off including holidays and volunteer events

Health insurance coverage for dependents on Day 1

401(k) Tuition reimbursement

Qualifications

• Minimum of two years of claims analysis experience required.
• One year of managed care or health insurance experience required.
• One year of Medicaid experience preferred.

Responsibilities

• Develop Pricing Agreement Templates for provider reimbursement setups.
• Resolve provider payment issues within established SLA timeframes.
• Analyze provider reimbursement and update codes and fee schedules.

Skills

Claims processing

Provider data maintenance

Analytical skills

Education

Associate Degree

Job description

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

Join AmeriHealth Caritas Ohio as a Provider Network Operations Analyst. In this role, you will be part of a collaborative and innovative team. You will be part of the operations team supporting the Ohio contract's loading and maintenance of provider data.

Work Arrangement: Remote

The Provider Network Operations Analyst will be responsible for the following:

• 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 working knowledge of processing rules, contractual guidelines, state/Plan policy, and operational procedures to provide technical expertise and business rules effectively.
• Participate in encounter rejection reconciliation activities.
• Responsible for analyzing 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 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 by regularly reconciling 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.

Education/Experience:

• Associate Degree preferred
• A minimum of two (2) years of claims analysis experience
• A minimum of one (1) year of managed care or health insurance experience
• A minimum of one (1) year of Medicaid experience is preferred
• Claims processing and provider data maintenance knowledge are required

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.

Discover more about us at www.amerihealthcaritas.com.

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