Senior Provider Network Operations Analyst

RPMGlobal; Northern (KY); Hybrid; USD 90,000 - 120,000; Full time

Job summary

RPMGlobal is seeking a Senior Provider Network Operations Analyst to join our remote team in the United States. The role focuses on operational accuracy, regulatory compliance, claims configuration, and provider data within Provider Network Operations.

The candidate will review reimbursement configurations, audit PI edits, and manage state-specific provider issues while coordinating changes with the Enterprise Operations Configuration Department.

Qualifications

• 3–5 years of claims analysis experience in healthcare, managed care, or Medicaid environments preferred.
• Claims processing and provider data maintenance knowledge required.
• Understanding of healthcare claims payment configuration process/systems and its impact on network operations.

Responsibilities

• Review and validate provider reimbursement and claim configuration requests per regulatory and contractual requirements.
• Audit Payment Integrity (PI) vendor and internal edits/projects/recoveries.
• Analyze Facets claims edit configuration requests from intake to submission and impact assessment.
• Encounter error reconciliation and management, identifying changes to mitigate future errors.
• Manage state-level provider issues and escalations; monitor state communications and lead action determinations.
• Lead policy/contract changes analysis and coordinate with stakeholders
• Support internal and vendor reimbursement policies and identify cost containment opportunities.
• Manage single-case agreements and liaise with Provider Network Management
• Maintain knowledge of processing rules, contracts, state plans and operational procedures.

Skills

Tech-business communication

Education

AAPC CPC/COC/CIC/CRC certification

NHA CBCS certification

Associate’s degree

Tools

Microsoft Excel

Microsoft Access

Microsoft Word

Pivot charts

Job description

Senior Provider Network Operations Analyst

Location Remote, United States Primary Job Function Medical Management ID** 45068

Role Overview:

The Senior Provider Network Operations Analyst serves as a subject matter expert within Provider Network Operations and is responsible for operational accuracy, regulatory compliance, claims configuration, provider data, and related network operations.

Work Arrangement:

• Remote - This position is fully remote and will require the associate to work during Central/Eastern Standard Time (CST/EST) hours.
• Candidates must have access to reliable high-speed internet (minimum 50 Mbps download / 5 Mbps upload).
• Associates in locations where required may be eligible for internet reimbursement based on applicable regulations.

Responsibilities:

• Review, analyze, and validate provider reimbursement and claim configuration requests in alignment with regulatory and contractual requirements.
• Review/approve and audit Payment Integrity (PI) vendor and internal prospective and retrospective edits/projects/recoveries
• Analyze Facets claims edit configuration requests to include intake and review of requests, impact assessment, and submission to Enterprise Operations.
• Encounter error reconciliation, representation, oversight, and management, including identification and initiation of claim or provider changes necessary to mitigate/prevent future errors
• Manage and resolve state complaints and escalated provider issues
• State policy and contract amendment changes analysis and management
• 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
• Manage internal and vendor reimbursement policies; identify trends for cost containment changes and initiatives
• Single-case agreement management/ownership, including letter development and coordination with Provider Network Management (PNM)
• Serves as the subject matter expert in state-specific 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

Education & Experience:

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

Skills & Abilities:

• Ability to focus on technology and business issues, as well as communicate appropriately with both technology and business experts