Provider Reimbursement & Network Services Analyst I/ii/iii

Network Services Analyst

Summary:

Under the general direction of the Assigned Management, and in accordance with sound and ethical procedures, objectives and controls, a Network Services Analyst analyzes and evaluates the composition and characteristics of Health Plan provider networks. This position also is responsible for the development of consistent payment methodologies and negotiates allowances for out of area/out of network non-par claims.

In the course of this work, the Analyst will be required to work closely with others to assemble and produce documentation and informational materials that will guide Senior Management in making strategic network specific business decisions.

Essential Accountabilities:

All Levels - Manages and supports various projects with implications for all lines of business. These projects arise in response to shifts in marketplace dynamics, changes in the delivery of healthcare services, or the emergence of new products. Responsibilities include, but are not limited to:

• Differentiates claim types and navigates through the various claims platforms.
• Uses pricing tools and efficiency in the varying payment methodologies.
• Gathers data from a variety of sources; updates and maintains a variety of; prepares financial reports, statements and analysis for management review.
• Performs assigned analysis and/or assists in complex analysis for supervisory review, creates models and makes recommendations based on the analysis completed.
• Assists in the determination of the impact of various business options for strategic planning and other financial decisions.
• Assists in accumulation and evaluation of data from outside sources to negotiate pricing for out of area/network services. Develops letter of agreement then notifies claims department that service has been priced.
• Responsible for the development and analyses of supporting financial schedules, including preparation of worksheets, maintenance of appropriate backup and documentation for internal control and auditing purposes.
• Supports and maintains contracting and relationship responsibilities associated the utilization of the Blue and non-Blue national/regional provider network(s), including development and maintenance of vendor contracts, tracking of open issues, leading team efforts to matrix manage open network issues relative to prospective employer groups, tracking and status reporting for senior management.
• Creates and maintains network tracking reports by product and by region, including threatened resignation reports, specialty inventory reporting, provider specific product participation reporting, assessing analytics to identify potential network gaps and recommendations for change.
• Supports product development initiatives such as development of networks to service Safety Net and Medicare products. This includes development of reports on products, network strategies, status reporting on activity, financial information preparation for negotiators.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Works with larger, more complex, higher visibility accounts that have been escalated. Develops and maintains more complex vendor contracts.
• Identify root cause of problems; develop potential options and likely outcomes of each option; Recommend optimal option.
• Model financial impact of change to reimbursement methodology on an individual claim basis; Articulates impact of changing from one reimbursement methodology to an alternate.
• Analyzes, identifies and recommends improvements to the claims process and inventories such as triaging misrouted cases, conducting cost and quality analyses.
• Maintains appropriate backup and documentation to ensure regulatory compliance is being met.
• Demonstrates adherence to internal controls surrounding regulatory compliance and have ability to explain same.

Level III (in addition to Level II Accountabilities)

• Facilitates cross-functional workgroups and internal meetings to present recommendations and lead workgroup to determine best course of action to implement corrections to system or process improvement opportunities. Presents information clearly.
• Discusses complex out of network claims with providers and recommends solutions. Tracks unusual and/or outstanding claims.
• Identifies trends and opportunities with network management/negotiators, etc.; presents findings and recommendations to management.
• Works with key stakeholders to create improvements as either a dedicated resource or with overall division processes to ensure end to end continuity.
• Analyzes and interprets complex records/documentation; reviews and assesses validity of financial estimates from a variety of sources against stated business objectives.
• Acts in a consultative capacity to management at all levels of assigned organization unit to provide professional technical expertise in the determination of suitable approaches to reimbursement concerns.
• Applies principles of total quality management, team leadership, facilitates peer review activities on a consistent, ongoing basis to identify and remove barriers to increased productivity, quality, cost effectiveness, and timeliness of operations and customer satisfaction.
• Designs and develops reports which illustrate integrated solutions to meet business needs or enhance performance.
• Reviews and approves project cost/benefit analyses prior to presentation to company management.
• Acts as a mentor to the team by setting, and striving to achieve high levels of professional competence. Leads by example.

Minimum Qualifications:

NOTE: This description includes multiple levels of classification. The levels of classifications are differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making and in some cases, becoming a resource to others. New hires will be placed in the level for which they are most qualified based on their experience, credentials and skills.

All Levels

• Bachelor's degree in Health Care Administration, Business, Finance or relevant field with a minimum of four years health care experience in an analytical function, plus a minimum of one year of business user experience including negotiation, research, analysis and working with outside customers.
• In lieu of degree, a minimum of eight years health care/business experience in an analytical function including a minimum of one year of business user experience including negotiation, research, analysis and working with outside customers.
• Ability to read and understand contractual language – weave through it and be able to negotiate on layman's terms.
• Strong analytical, written and oral communication, organizational and time management skills.
• Proficiency in Microsoft Office suite.
• Ability to work with the various levels of internal management and external audiences.

Level II (in addition to Level I Qualifications)

• A minimum of five years health care experience in an analytical function, plus a minimum of one year of business user experience including negotiation, research, analysis and working with outside customers.
• Excellent written and oral communications skills in addition to strong organizational and time management skills are required.
• Strength in spreadsheet, data base, word processing and Microsoft Office products.
• Ability to present and communicate complex issues with fluency and expertise.
• Must be able to interact comfortably with all levels of management.
• Relationship building skills required

Level III (in addition to Level II Qualifications)

• A minimum of seven years health care analytical experience, plus a minimum of two years of business user experience including negotiation, research, analysis and working with outside customers.
• Ability to identify trends and opportunities with network management/negotiators, etc.; presents findings and recommendations.
• Demonstrated leadership, decision-making and team building skills.
• In addition to solid oral and written skills, must have solid presentation skills.
• Certification preferred in Lean Six Sigma Green Belt.
• Excellent presentation skills.

Physical Requirements:

• Use of computers and phone
• Ability to have limited travel

Compensation Range(s):

Level I (E1 Pay Grade): Minimum: $62,400 - Maximum: $84,000

Level II (E2 Pay Grade): Minimum: $62,400 - Maximum: $96,081

Level III (E3 Pay Grade): Minimum: $62,400 - Maximum: $106,929

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position