Priority Health · 7 hours ago
Provider Operations Analyst
Grand Rapids, MI
Full-time
Onsite
Entry Level
2+ years expPriority Health is a nationally recognized health system committed to delivering personalized healthcare. The Provider Operations Analyst is responsible for analyzing provider operations data, ensuring compliance, and resolving complex provider issues to enhance operational efficiencies across a large network of providers.
Health Care
Responsibilities
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 provider’s 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 82,000+ 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, determining accurate payment of claims, and ensure annual payment of multi-million dollar access fees are paid accurately and timely to all national networks
Departmental subject matter expert who determines root cause and takes necessary action to resolve. Ensure effective communication of resolution to appropriate next level. Acts as a mentor to Provider Operations Associate Analyst
Qualification
Required
High School Diploma or equivalent
2 years of relevant experience in healthcare, insurance, managed care and/or comparable industry or related field
1 year of relevant experience in an operations area
Preferred
Associate's degree or equivalent
Bachelor's degree
1 year of relevant 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
1 year of relevant experience with provider configuration, credentialing, claims and/or comparable systems
1 year of relevant 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
CRT-Professional Medical Services Management, Certified (CPMSM)
Benefits
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
Company
Priority Health
Priority Health is an award-winning health benefits company.
1001-5000 employees
H1B Sponsorship
Priority Health 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 (6)
2024 (9)
2023 (9)
2022 (10)
2021 (5)
2020 (8)
Funding
Current Stage
Late StageTotal Funding
$0.5MKey Investors
Michigan Health Endowment Fund
2022-02-24Grant· $0.5M
Leadership Team
Nick Gates
President
Recent News
2025-12-11
Morningstar.com
2025-11-18
Company data provided by crunchbase