Provider Reimbursement & Network Services Analyst I​/II​/III

Overview

Job Description: Under the general direction of Assigned Management, a Network Services Analyst analyzes and evaluates the composition and characteristics of Health Plan provider networks. The role includes developing consistent payment methodologies and negotiating allowances for out‑of‑area/out‑of‑network non‑PAR claims.

In this capacity the analyst works closely with others to assemble and produce documentation and informational materials that guide senior management in making strategic network‑specific business decisions.

• Differentiates claim types and navigates various claims platforms.
• Uses pricing tools to optimize payment methodologies.
• Gathers data from multiple sources, updates and maintains it; prepares financial reports, statements and analyses for management review.
• Performs assigned analysis and assists in complex analysis for supervisory review, creates models and makes recommendations based on completed analysis.
• Assists in determining the impact of various business options for strategic planning and other financial decisions.
• Accumulates and evaluates data from outside sources to negotiate pricing for out‑of‑area/out‑of‑network services. Develops a letter of agreement and notifies the claims department that the service has been priced.
• Develops and analyzes supporting financial schedules, including preparation of worksheets, and maintains backup and documentation for internal control and auditing purposes.
• Supports and maintains contracting and relationship responsibilities for the utilization of Blue and non‑Blue national/regional provider networks, including development and maintenance of vendor contracts, tracking of open issues, and leading team efforts to manage network issues relative to prospective employer groups. Tracks status and reports for senior management.
• Creates and maintains network tracking reports by product and region, including threatened resignation reports, specialty inventory reporting, and provider‑specific product participation reporting. Assess analytics to identify potential network gaps and recommend changes.
• Supports product development initiatives such as development of networks to service Safety Net and Medicare products. Produces reports on products, network strategies, status, and financial information for negotiators.
• Consistently demonstrates high standards of integrity by supporting Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with corporate privacy policies and procedures.
• Exhibits regular and reliable attendance.
• Performs other functions as assigned by management.

• Works with larger, more complex, high‑visibility accounts that have been escalated. Develops and maintains more complex vendor contracts.
• Identifies root cause of problems; develops potential options and likely outcomes of each option; recommends the optimal option.
• Models the financial impact of changes to reimbursement methodology on an individual claim basis; articulates impact of switching from one methodology to an alternative.
• Analyzes, identifies, and recommends improvements to the claims process and inventories, such as triaging misrouted cases and conducting cost and quality analyses.
• Maintains appropriate backup and documentation to ensure regulatory compliance.
• Demonstrates adherence to internal controls surrounding regulatory compliance and explains them as required.

• Facilitates cross‑functional work groups and internal meetings to present recommendations and lead work groups in determining the best course of action for 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, presents findings and recommendations to management.
• Works with key stakeholders to create improvements either as a dedicated resource or within division processes to ensure…