Analyst, Provider Operations

Provider Operations Analyst

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 eco system. 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 provider's 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 eco system, 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, determining accurate payment of claims, and ensure annual payment of multi-million dollar access fees are paid accurately and timely to all national networks.
• Departmental subject matter expert who determines root cause and takes necessary action to resolve. Ensure effective communication of resolution to appropriate next level. Acts as a mentor to Provider Operations Associate Analyst.

Qualifications

Required :

Preferred :

About Corewell Health

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.

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 : 00 a.m. - 5 : 00 p.m.

Days Worked

Monday - Friday

Weekend Frequency

N / A