Network Services Analyst I​/II​/III

Job Description

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.

• 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; 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.

• 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.

• Facilitates cross-functional work groups and internal meetings to present…