Remote Senior Provider Network Operations Lead (MI)

RPMGlobal; Southfield (MI); Hybrid; USD 70,000 - 100,000; Full time

Job summary

RPMGlobal in Southfield, MI is seeking a Senior Provider Network Operations Analyst to ensure operational accuracy, regulatory compliance, and accurate claims configuration within Provider Network Operations.

The role requires auditing PI edits, UAT reviews, and managing provider data changes, with heavy emphasis on state policy, HVO edits, and MS Office data analytics. Remote-work option within Michigan with monthly in-person meetings.

Qualifications

• AAPC/CPC, COC, CIC, CRC or NHA/CBCS certification required.
• Associate degree preferred or equivalent experience in healthcare.
• 3–5 years of claims analysis experience in healthcare, managed care, or Medicaid environment preferred.
• Claims processing and Provider data maintenance knowledge required.
• Understanding of healthcare claims payment configuration processes/systems and their impact on network operations required.
• Strong knowledge of MS Excel, Access, Word; pivot charts and data analytics.

Responsibilities

• Review/approve and audit Payment Integrity (PI) vendor and internal edits/projects/recoveries.
• UAT/client review & audit of provider data, AGID configuration, and setup concentration.
• Facets claims edit configuration – intake, 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; identify and initiate provider changes to mitigate future errors.
• Management and resolution of state complaints; monitor state policy changes and amendments.
• Internal or vendor medical policy or Health Value Optimization (HVO) edit changes and initiatives.
• Monitor state communications; lead initial action analysis and coordinate work requests to analysts.
• BPO and/or other intake/workflow tool management.
• Single-case agreement management/ownership and coordination with Provider Network Management.

Skills

Tech/Business communication

Data analytics

Excel / MS Office

Education

AAPC certification / NHA certification

Associate degree preferred

Tools

MS Excel

Pivot charts

Access databases

Job description

RPMGlobal in Southfield, MI is seeking a Senior Provider Network Operations Analyst to ensure operational accuracy, regulatory compliance, and accurate claims configuration within Provider Network Operations.

The role requires auditing PI edits, UAT reviews, and managing provider data changes, with heavy emphasis on state policy, HVO edits, and MS Office data analytics. Remote-work option within Michigan with monthly in-person meetings.