Provider Operations Analyst Associate
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Job Location:
Grand Rapids, MI - USA
Monthly Salary:
Not Disclosed
Posted on:
03-11-2025
Vacancies:
1 Vacancy
Job Summary
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.
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 providers 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 82000 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
Required
1 year of relevant experience in healthcare insurance managed care and/or comparable industry
Preferred
Associates degree or equivalent
1 year of relevant experience in an operations area
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
Experience with provider configuration credentialing claims and/or comparable systems
Experience in running reports utilizing Access databases Business Objects Report Writer and/or comparable reporting tools
CRT-Provider Credentialing Specialist Certified (CPCS) - NAMSS National Association Medical Staff Services preferred Or
CRT-Professional Medical Services Management Certified (CPMSM) - UNKNOWN Unknown
How Corewell Health cares for you
Comprehensive benefits package to meet your financial health and work/life balance goals. Learn more here.
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 RapidsDepartment Name
PH - Credentialing and EnrollmentEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8 a.m. to 4:30 p.m.Days Worked
Monday to FridayWeekend Frequency
N/ACURRENT COREWELL HEALTH TEAM MEMBERS Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members patients visitors and community. We require a drug-free workplace and require team members to comply with the MMR Varicella Tdap and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process to perform the essential functions of a job or to enjoy equal benefits and privileges of employment due to a disability pregnancy or sincerely held religious belief.
Corewell 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 gender pregnancy sexual orientation gender identity or expression veteran status or any other legally protected category.
An interconnected collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. As a health system we advocate for equity as we care for our patients our communities and each other. From workshops that develop cultural intelligence to our inclusion resource groups for people to find community and empowerment at work we are dedicated to ongoing resources that advance our values of diversity equity and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
Required Experience:
IC
Key Skills
- Business
- Information Management
- Accounting
- Corporate Risk Management
- Faculty
- Jms
About Company
Corewell Health is committed to granting equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status
