The Provider Network Operations Analyst II is responsible for creating the claims system reimbursement structure for clinic and ancillary providers based on the legal provider contract for Medica’s Commercial Group, Individual, Government, PPO, LaborCare and Patient Choice/Insight products. The Analyst II is responsible for the accuracy of the provider reimbursement within the COSMOS, COPIS and UNET platforms for more complex payment methodologies, thus affecting the financial impact of claims payment to the member and provider in addition to impacts to financial/utilization reporting. This role requires complex problem solving and critical thinking skills, attention to detail and a broader knowledge of provider reimbursement methodology than the Analyst I position.
The Analyst II will be responsible for day to day issues, interpretation of all provider contracts, collaboration with other departments and accurate creation and input of the provider contract reimbursement. This position works cross-functionally with and acts as a subject matter expert on the provider contract installation process. A firm understanding of provider contracting, fee schedules and reimbursement process is necessary in addition to a general understanding of review tables, modifier tables, manual claims P&P’s and claims adjudication.
In addition to these core responsibilities, the Analyst II will run Adhoc reports, perform mass maintenance updates to provider records, participate in internal and external audit projects and conduct multiple quality checks to ensure data integrity within all databases housing provider reimbursement. The Analyst II will also learn and participate in all aspects of business testing of appropriate provider databases when enhancements are being programmed and deployed by Medica IT or UHG.
This position involves working with customers from multiple internal Medica departments, multiple departments at UHG in addition to external vendors where they must build effective relationships to collaboratively ensure data is accurate for Medica, SelectCare, LaborCare and Patient Choice member’s, employer groups, brokers and providers. It is important that the Analyst II fully understand the upstream and downstream impacts of loading correct data and possess the ability to recognize and communicate potential upstream and downstream impacts.
The Provider Network Operations Analyst II functions within a production environment and is expected to meet production, TAT and quality standards. At times, they will be faced with shifting priorities or situations where multi-tasking is needed therefore, the Analyst II must possess the ability to adapt to change quickly. This position involves creating or maintaining written documentation of each contract installation in addition to creation and/or maintenance of manual claims P&P’s used by UHG claim processors. They will also be responsible for the creation and/or maintenance of related internal policies and processes therefore, the ability to document information logically and effectively is expected.
- Installation of provider contract
- Issue Resolution
- Quality and Production
- Provider Network Operations Fundamentals
- Bachelor’s degree
- 2+ years experience in managed care and insurance products and services
Specific types of experience:
- Relevant work experience in provider contracting/installation
- Relevant work experience working with outsourced business processes
- Ancillary knowledge a plus
- Medica, SelectCare, LaborCare and/or Patient Choice product knowledge and experience preferred
- Strong PC skills including Microsoft applications (NT, Word, Excel, Project, PowerPoint and Access) and Visio (or equivalent)
- COSMOS, COPIS and/or NetworksPro database knowledge a plus
Skills and Abilities:
- Quality focus: Attention to accuracy is critical
Accountable: Able to meet standards for production, quality and turn-around time
Quick Learner: Able to learn quickly and respond to a changing industry and operational environment.
Analytical: Must be detail oriented
Multi-Tasker: Must possess the ability to handle multiple transactions or tasks at the same time
Demonstrated ability to deal with customers and rapid changing environment
Ability to shift priorities comfortably
Ability to work as an individual and also as part of a team
Professional and courteous demeanor
Highly organized and able to manage multiple deadlines in a fast-paced environment
Strong verbal and written skills
Ability to develop a hands-on understanding of multiple varieties of software applications
Troubleshooting ability and sound decision making skills are critical