Provider Operations Analyst II

Role Overview

• Develop queries to identify and quantify provider data issues within the organization and assist in the development plans to resolve data issues
• Provide operations teams; Contracting, Credentialing, Data Load, Directories, and Pended Claims with analysis and oversight for all provider data, workflows and processes
• Act as Subject Matter Expert (SME)/Business Analyst/Data Analyst for Provider Operations team on various initiatives/special projects
• Work cross functionally with Claims, Configuration, Market Reps, and Provider Operations to integrate business processes and workflows
• Identify, develop, and implement reporting and/or business processes to ensure adherence to data quality, operational excellence, regulatory and compliance requirements
• Develop and monitor daily metrics for staff quality, productivity, making recommendations for change as needed
• Manage and conduct root cause analysis for high-level escalations that involve intensive research and resolution
• Manage special projects through to resolution that may involve high dollar unpaid claims, risk of state complaint, risk of provider refusing to serve CareSource member(s), or risk of not meeting compliance requirements
• Develop, document and perform testing and validation as needed for process and system changes
• Serve as a primary point of contact for vendors and business partners that are sending and receiving CareSource provider data
• Submit appropriate requests through the operations workflow to make updates on provider data
• In collaboration with Talent Development, develop and present training modules and responsible to present to staff as needed
• Perform any other job duties as requested

Requirements

• Bachelor’s Degree or equivalent years of relevant work experience is required
• A minimum of three (3) years of health care or managed care experience is required
• Experience working on a Claims systems, preferably Facets, preferred
• Experience in provider relations, contracting, onboarding, credentialing, directories, pended claims, or configuration is highly preferred
• Overall knowledge and understanding of one or more key provider systems, including Choreo/Contract Manager, Cactus and Facets.
• Ability to manage multiple initiatives exhibiting excellent organizational and collaboration skills
• Demonstrates excellent analysis and supporting technical skills to include SQL/Access capabilities
• Time management skills, ability to develop, prioritize and accomplish goals with a sense of urgency
• Ability to multi-task and remain flexible during organizational and/or business changes

Tech Stack

• SQL

Benefits

• substantial and comprehensive total rewards package
• bonus tied to company and individual performance