Senior Provider Network Operations Analyst

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

Senior Provider Network Operations Analyst Location Southfield, MI Primary Job Function Medical Management ID** 45081

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; the associate must be located in Michigan (MI and attend monthly meetings as needed in Southfield, MI.
• Requires reliable high-speed internet (minimum 50 Mbps download / 5 Mbps upload)
• Internet reimbursement may be available where required by law or contract

Responsibilities:

• Review/approve and audit Payment Integrity (PI) vendor and internal prospective and retrospective edits/projects/recoveries.
• User Acceptance Testing (UAT)/Client Review & audit (provider data, Appian Advanced Group ID (AGID) configuration, and set-up concentration) reviews requests prior to initial submission to Enterprise Operations (EO) and claims post-production.
• Facets claims edit configuration concentration (Appian) – intake, review, 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 – including identification and initiation of claim or provider changes necessary to mitigate/prevent future errors.
• Management and resolution of state complaints.
• State policy and contract amendment changes analysis and management.
• Internal or vendor medical policy or Health Value Optimization (HVO) edit changes and initiatives.
• 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.
• Business Process Outsourcing (BPO) and/or other intake/workflow tool management.
• Single-case agreement management/ownership, including letter development and coordination with Provider Network Management (PNM).
• 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 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