AmeriHealth Caritas · 3 hours ago
Senior Provider Network Operations Analyst
Manchester, NH
Full-time
Hybrid
Mid, Senior Level
3+ years expAmeriHealth Caritas is a healthcare organization, and they are seeking a Senior Provider Network Operations Analyst responsible for maintaining provider data and addressing inquiries related to claim payment issues. The role involves reviewing and auditing payment integrity, managing state complaints, and serving as a subject matter expert in health reimbursement rules.
Health CareInformation Technology
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
Qualification
Required
American Academy of Professional Coders (AAPC) certification (CPC, COC, CIC, CRC) or NHA (CBCS) certification required
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
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
Preferred
Associate's degree preferred, or equivalent combination of education and experience in a healthcare field
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
Company
AmeriHealth Caritas
AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.
10001+ employees
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)
Funding
Current Stage
Late StageLeadership Team
Kathleen Giblin
SVP Clinical Operations
Ash Hanson
Executive Vice President & Chief Human Resources Officer
Recent News
2025-11-06
The Philadelphia Inquirer
2025-10-02
2025-10-01
Company data provided by crunchbase