Provider Operations Analyst Associate

Provider Operations Associate

A Provider Operations Associate is responsible for identifying and solving issues relating to the performance of the provider operations business. 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. Operation Analyst must possess strong attention to detail along with business acumen fueled by sharp analytical skills.

Essential Functions

• 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, but not limited to, collaboration with physician groups to best relocate members to the appropriate primary care provider, collaboration with Priority Health member enrollment division, and Provider Network Performance division all to ensure that Priority Health members are receiving the right care with the right provider.
• Performs analysis, and independent evaluation and ongoing monitoring of provider credentials (licensure, malpractice, etc.), as applicable, in order 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 entire network of 82,000+ providers, provider groups, facilities, and national network providers, to resolve complex provider issue resolution. Resolves complex issues that results from the entire PH ecosystem, i.e., medical authorization, provider contract setup, claims payment, finance, etc.
• Manages the repricing of claims for PH national provider network (Cigna) including overall review of claims, denying claims, and determining accurate payment of claims.
• Performs self-audits and participates in audit process. Based on the audit analysis, this role determines actions necessary to correct erroneous provider demographic and contractual data to positively affect accurate claims processing and payment.

Qualifications Required

Preferred

How Corewell Health cares for you

Comprehensive benefits package to meet your financial, health, and work / life balance goals. 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 SITE - Priority Health - 1239 E Beltline - Grand Rapids Department Name PH - Credentialing and Enrollment Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 40 Hours of Work 8 a.m. to 4 : 30 p.m. Days Worked Monday to Friday Weekend Frequency N / A