Provider Operations Analyst Associate

Spectrum Health; Grand Rapids (MI); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Comprehensive benefits

On-demand pay

Discounts directory

Identity protection

Retirement options

Job summary

Corewell Health is seeking a Provider Operations Associate to analyze provider enrollment data and resolve issues across Priority Health ecosystem. You will coordinate with provider networks and internal teams to ensure accurate claims processing and correct incentive settlements.

The role emphasizes attention to detail, data integrity, and compliance with CMS, NCQA, and related standards, supporting 82,000+ providers and national network operations.

Qualifications

• Required: Associate's Degree or equivalent.
• Required: 1 year of relevant experience in healthcare, insurance, managed care and/or comparable industry.
• Preferred: Experience with accreditation and/or regulatory bodies like NCQA, CMS, MDCH, TJC, etc., standards related to credentialing and/or billing, and/or quality auditing requirements.
• Preferred: Experience with provider configuration, credentialing, claims and/or comparable systems.
• Preferred: Experience in running reports utilizing Access databases, Business Objects Report Writer, and/or comparable reporting tools.

Responsibilities

• Discerns, initiates, and maintains provider enrollment information in Evips and Facets accurately and timely.
• Performs analytics to determine provider to member primary care affiliation when providers move locations.
• Monitors provider credentials to meet CMS, accreditation and regulatory requirements.
• Ensures data collection and accuracy for CMS service area expansion and Medicaid reporting.
• Manages repricing of claims for PH national network and reviews/denies claims as needed.
• Performs self-audits and participates in audit processes.
• Contributes to safety initiatives and ensures regulatory compliance.

Skills

Attention to detail

1 year healthcare experience

Education

Associate's Degree or equivalent

Tools

Access databases

Business Objects Report Writer

Reporting tools

Job description

Job Summary

A Provider Operations Associate is responsible for identifying and solving issues relating to the performance of the provider operations business. To do so, vast amounts of data and information must be analyzed and reviewed with the cooperation of the provider network community and internal departments. The operations analyst is responsible for the oversight of the provider enrollment data and issue resolution arising throughout the entire Priority Health eco system. Operation Analyst must possess strong attention to detail along with business acumen fueled by sharp analytical skills.

Essential Functions

Discerns, initiates, and maintains the complex provider enrollment information in both Evips and Facets systems accurately and timely to ensure the annual multi-million-dollar claims payout and the annual multi-million-dollar Physician Incentive Program settlement payout to provider’s is correct. Performs analytics to determine provider to member primary care affiliation when providers move from locations. This involves, but not limited to, collaboration with physician groups to best relocate members to the appropriate primary care provider, collaboration with Priority Health member enrollment division, and Provider Network Performance division all to ensure that Priority Health members are receiving the right care with the right provider. Performs analysis, and independent evaluation and ongoing monitoring of provider credentials (licensure, malpractice, etc.), as applicable, in order to meet Priority Health criteria, state, accreditation and CMS compliance requirements and high standards. Ensures collection, storage and accuracy of product specific data for CMS service area expansion, network adequacy reporting and Medicaid Provider reporting. Performs gap analysis. Manages and implements organizational operational efficiencies for the entire network of 82,000+ providers, provider groups, facilities, and national network providers, to resolve complex provider issue resolution. Resolves complex issues that results from the entire PH eco system, i.e., medical authorization, provider contract setup, claims payment, finance, etc. Manages the repricing of claims for PH national provider network (Cigna) including overall review of claims, denying claims, and determining accurate payment of claims. Performs self-audits and participates in audit process. Based on the audit analysis, this role determines actions necessary to correct erroneous provider demographic and contractual data to positively affect accurate claims processing and payments. Actively participates in safety initiatives and risk mitigating measures where appropriate and completes all position and unit safety related competencies and requirements on a timely basis. Performs other duties as assigned.

Qualifications

Required

• Associate's Degree or equivalent
• 1 year of relevant experience in healthcare, insurance, managed care and/or comparable industry

Preferred

• 1 year of relevant experience in an operations area
• Experience with accreditation and/or regulatory bodies like NCQA, CMS, MDCH, TJC, etc., standards related to credentialing and/or billing, and/or quality auditing requirements.
• Experience with provider configuration, credentialing, claims and/or comparable systems.
• Experience in running reports utilizing Access databases, Business Objects Report Writer, and/or comparable reporting tools.
• CRT-Provider Credentialing Specialist, Certified (CPCS) - NAMSS National Association Medical Staff Services
• CRT-Professional Medical Services Management, Certified (CPMSM)

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

Employment Details

• Primary Location SITE - Priority Health - 1241 E BeltlineAve NE - Grand Rapids
• Department Name Credentialing and Enrollment - PH Managed Benefits
• Employment Type Full time
• Shift Day (United States of America)
• Weekly Scheduled Hours 40 Hours of Work
• 8:00 a.m. to 5:00 p.m.
• Days Worked Monday to Friday
• Weekend Frequency N/A

Workplace Requirements

We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category.

EEO Statement

We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447. People are at the heart of everything we do, and the inspiration for our legacy of outstanding outcomes, innovation, strong community partnerships, philanthropy and transparency. Corewell Health is a not-for-profit health system that provides health care and coverage with an exceptional team of 60,000+ dedicated people—including more than 11,500 physicians and advanced practice providers and more than 15,000 nurses providing care and services in 22 hospitals, 300+ outpatient locations and several post-acute facilities—and Priority Health, a provider-sponsored health plan serving more than 1.2 million members. Through experience and collaboration, we are reimagining a better, more equitable model of health and wellness.