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AmeriHealth Caritas · 1 month ago

Senior Provider Network Operations Analyst

Manchester, NH

Full-time

Hybrid

Mid, Senior Level

2+ years exp

AmeriHealth Caritas is seeking a Senior Provider Network Operations Analyst who will be responsible for maintaining provider data and addressing inquiries related to claim payments. The role includes reviewing provider billing, developing reimbursement templates, and ensuring compliance with state-specific health reimbursement rules.

Health CareInformation Technology

H1B Sponsor Likely

Responsibilities

Reviewing and auditing provider billing, claims processing and accuracy

Develops the Pricing Agreement Templates (PAT) for all provider reimbursement setups

Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched, and resolved within established SLA timeframes

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 provide technical expertise and business rules effectively

Participating in encounter rejection reconciliation activities

Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers

Participating in Provider Reimbursement medical policy and edit reviews

Requests/runs queries to identify root causes of claim denials, incorrect payments, and claims that are not correctly submitted for payment

Act as the resource to other departments by developing and managing work plans that document the status of key relationship issues and action items for high-profile providers

Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits

Validate potential recovery claim project activities

Maintain a tracking system of operational issues, progress, and status

Performs other related duties and projects as assigned

Qualification

Claims analysisHealthcare reimbursement knowledgeMicrosoft ExcelAAPC CertificationTechnical claims processingRoot cause analysisData maintenance knowledgeReport developmentCritical thinking

Required

2 plus years of claims analysis experience in a healthcare environment

American Academy of Professional Coders (AAPC) Certificate required

Critical thinking and root cause analysis skills are required

Ability to focus on technical claims processing and Provider data maintenance knowledge

Understanding of and experience with healthcare claims payment configuration processes/systems and their relevance/impact on network operations

Technical knowledge with the ability to develop reports including data, averages and trending

Preferred

Associate's degree preferred

1 to 2 years of managed care or Medicare experience preferred

Billing and coding experience is a plus

Strong with Microsoft Excel, Access, and Word, including pivot charts and analytics

Company

AmeriHealth Caritas

Glassdoor3.4

AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.

Founded in 1982

Philadelphia, Pennsylvania, USA

10001+ employees

http://www.amerihealthcaritas.com

H1B Sponsorship

AmeriHealth Caritas has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (18)

2024 (17)

2023 (12)

2022 (14)

2021 (4)

2020 (11)