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AmeriHealth Caritas Provider Network Analyst Senior DE in Newark, Delaware

Provider Network Analyst Senior DE

Location: Newark, DE

Primary Job Function: Medical Management

ID**: 24367

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

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 Philadelphia, 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 .

Responsibilities:

The primary purpose of the job is to be responsible for the maintaining current provider data and provider reimbursement set up, and to address provider/state inquiries as it relates to claim payment issues.

  • Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up.

  • Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched and resolved within established SLA time frames.

  • 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.

  • Participate in encounter rejection reconciliation activities.

  • Responsible for the analysis of 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 that are not correctly submitted for payment.

  • Act 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.

  • Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits.

  • Validate potential recovery claim project activities.

  • Maintain tracking system of operational issues, progress, and status.

  • Performs other related duties and projects as assigned.

Education/Experience:

  • Associate's Degree; Bachelor's Degree preferred

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

  • At least two (2)+ years of claims analysis experience in a healthcare environment

  • One (1) to two (2) years of experience in managed care or related experience preferred.

  • One (1) to two (2) years of Medicaid experience 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.

  • Billing and coding experience a plus.

  • Strong with MS Excel, Access, Word, MS Access, MS Office, Pivot Charts, Analytics.

EOE Minorities/Females/Protected Veterans/Disabled

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