Provider Operations Analyst

Overview

Job Summary A Provider Operations Analyst is responsible for identifying and solving issues relating to the performance of the provider operations business and is a subject matter expert to the Provider Operations Associate. 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 Priory Health ecosystem.

The Operations Analyst must possess strong attention to detail along with business acumen fueled by sharp analytical skills.

• 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 providers is correct.
• Performs analytics to determine provider-to-member primary care affiliation when providers move from locations. This involves collaboration with physician groups to relocate members to the appropriate primary care provider, collaboration with Priority Health member enrollment division, and Provider Network Performance division to ensure Priority Health members are receiving the right care with the right provider.
• Performs analysis, independent evaluation and ongoing monitoring of provider credentials (licensure, malpractice, etc.), as applicable, 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 network of 82,000+ providers, provider groups, facilities, and national network providers to resolve complex provider issue resolution. Resolves complex issues arising in the PH ecosystem, including medical authorization, provider contract setup, claims payment, finance, etc.
• Manages the repricing of claims for the PH national provider network (Cigna), including overall review of claims, denying claims, determining accurate payment of claims, and ensuring annual payment of multi-million dollar access fees are paid accurately and timely to all national networks.
• Acts as the departmental subject matter expert who determines root cause and takes necessary action to resolve. Ensures effective communication of resolution to appropriate next level. Serves as a mentor to the Provider Operations Associate Analyst.

• High School Diploma or equivalent
• 2 years of relevant experience in healthcare, insurance, managed care and/or comparable industry or related field
• 1 year of relevant experience in an operations area

• Associate’s degree or equivalent
• Bachelor's degree
• 1 year of relevant 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.
• 1 year of relevant experience with provider configuration, credentialing, claims and/or comparable systems.
• 1 year of relevant experience in running reports utilizing Access databases, Business Objects Report Writer, and/or comparable sizing tools.
• CRT-Provider Credentialing Specialist, Certified (CPCS) - NAMSS National Association Medical Staff Services
• CRT-Professional Medical Services Management, Certified (CPMSM)

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.

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• 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, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

• Primary Location
  :
  Priority Health - 1239 E Beltline Ave NE - Grand Rapids
• Department Name
  :
  Provider Resolution - PH Managed Benefits
• Employment Type
  :
  Full time
• Shift
  :
  Day (United States of America)
• Weekly Scheduled Hours
  : 40
• Hours of Work
  : 8:00 a.m.
  
  - 5:00 p.m.
• Days Worked
  :
  Monday - Friday
• Weekend Frequency
  : N/A

Corewell Health is committed to…