Provider Operations Analyst Associate

Spectrum Health   Grand Rapids, MI   Full-time
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Job Description

Job Summary

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 eco system. Operation Analyst must possess strong attention to detail along with business acumen fueled by sharp analytical skills.

This is a temporary position that will run for approximately 4 months.

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, 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
  • Preferred Associate's Degree or equivalent
  • 1 year of relevant experience in healthcare, insurance, managed care and/or comparable industry Required
  • 1 year of relevant experience in an operations area Preferred
  • 1 year 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 Preferred
  • 1 year experience with provider configuration, credentialing, claims and/or comparable systems Preferred
  • 1 year experience in running reports utilizing Access databases, Business Objects Report Writer, and/or comparable reporting tools Preferred
  • CRT-Provider Credentialing Specialist, Certified (CPCS) - NAMSS National Association Medical Staff Services preferred Or
  • CRT-Professional Medical Services Management, Certified (CPMSM) - preferred

    Primary Location

    SITE - Priority Health - 1239 E Beltline - Grand Rapids

    Department Name

    PH - Credentialing

    Employment Type

    Full time

    Shift

    Weekly Scheduled Hours

    40

    Hours of Work

    8:00 A.M. - 4:30 P.M.

    Days Worked

    Monday - Friday

    Weekend Frequency

    N/A

    Spectrum Health requires all team members to receive the COVID-19 vaccinations subject to certain exclusions based on the team member’s job category. Spectrum Health is committed to granting reasonable accommodations in accordance with applicable laws.

    Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health's application process. Contact us at 616-486-SHHR (7447).

    Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected

    category. See more here.

    This job is no longer available.

    Spectrum Health

    Grand Rapids, MI