Senior Provider Claims Analyst
AmeriHealth Caritas
Manchester, NH
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JOB DETAILS
LOCATION
Manchester, NH
POSTED
8 days ago
Work Arrangement:
+ Hybrid – The associate must be in the office at least three (3) days per week at our Manchester, New Hampshire (NH) location.
Responsibilities:
+ Review/approves and audits 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:
+ Associate’s degree preferred, or equivalent combination of education and experience in a healthcare field.
+ American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, CRC) or NHA (CBCS) certification required.
+ 3 to 5 years of claims analysis experience in healthcare, managed care, or Medicaid environment preferred.
+ Strong working knowledge of Microsoft Excel, Access, Word, and other MS Office tools; ability to work with pivot charts, Access databases, and data analytics.
+ 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
Skills & Abilities:
+ Ability to focus on technology and business issues, as well as communicate appropriately with both technology and business experts
+ Superior organizational skills required
+ Critical thinking skills
+ Strong customer service skills
+ Data and reporting analysis
As a company, we support internal diversity through:
Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.
About the Company
A
AmeriHealth Caritas
Leaders in health care solutions for those most in need
AmeriHealth Caritas is the nation's leader in providing comprehensive health care solutions for those in most need and the chronically ill. We impact the lives of more than 5.7 million members nationwide. With more than 30 years of experience managing care for individuals and families in publicly-funded programs, we have become known for developing innovative solutions that help improve health outcomes while reducing costs.
Our mission, our goal
Our mission is to help people get care, stay well and build healthy communities. Our goal is to provide responsible managed care solutions, including Medicaid, Medicare, and CHIP - plus behavioral health, pharmacy benefits management and third-party management and administrative services.
COMPANY SIZE
5,000 to 9,999 employeesINDUSTRY
Healthcare Services
FOUNDED
1985
WEBSITE
http://www.amerihealthcaritas.com