Senior Provider Network Analyst

Job Summary

The Senior Provider Network Analyst serves as a subject‑matter expert in provider network operations, data integrity, and configuration management. This role is responsible for conducting advanced research, complex analysis, and strategic problem‑solving related to provider network issues. The incumbent provides expert support for new business initiatives, provider recruitment, managed care contracting, and the development of operational improvements that optimize network performance and plan compliance.

Key Responsibilities

• Identifies systematic, procedural, and cross‑functional issues by conducting advanced data analysis; independently initiates corrective actions and drives resolution across operational teams.
• Extracts, manipulates, audits, and validates large and complex provider data sets to ensure accuracy for new implementations, expansions, and enterprise initiatives.
• Serves as the escalation point for ensuring ongoing compliance with provider contracts, regulatory requirements, and plan policies, identifying gaps, and recommending corrective strategies.
• Performs sophisticated statistical and financial analysis to evaluate provider performance, cost impacts, reimbursement trends, and opportunities for process and system improvement.
• Utilizes provider contract maintenance software to design, develop, and optimize contract templates, fee schedules, and credentialing configurations with minimal oversight.
• Leads or co‑leads configuration and testing efforts for new report development, system enhancements, and business requirements tied to provider network functions.

Configuration Responsibilities

• Conducts advanced data mining and analytics to determine correct system configuration, demonstrating deep expertise in interpreting business rules, state requirements, and contract terms.
• Translates complex provider agreements, state and government programs, and policy requirements into accurate and scalable configuration parameters.
• Independently interprets, provider contracts related to fee schedules, reimbursement methodologies, and system tables for both issue resolution and new configuration builds.
• Leverages prior experience to research, triage, and resolve high‑complexity claims/encounter issues, including pended claims, system defects, and reimbursement discrepancies.
• Manages fluctuating work volumes while prioritizing tasks to meet aggressive deadlines, supporting both operational and strategic needs of internal stakeholders.

Leadership and Responsibilities

• Acts as subject matter expert (SME) for provider data integrity, configuration standards, reimbursement methodologies.
• Provides mentoring, coaching, and informal leadership to junior analysts, offering oversight on analytical methodologies, quality reviews, and configuration work.
• Serves as a lead analyst on cross‑functional projects, representing the provider network area in enterprise initiatives and system upgrades.

Strategic and Analytical Responsibilities

• Independently identifies trends, root causes, and systemic issues within provider data, claims processing, and reimbursement logic; recommends strategic solutions to leadership.
• Conducts impact analyses for regulatory changes, benefit updates, and contract modifications, presenting findings and recommendations to leadership.
• Develops advanced dashboards, scorecards, reporting tools, and analytic models to support provider network strategy, performance monitoring, and decision‑making.

Advanced Technical Competencies

• Use advanced Excel, or analytic tools to perform complex data manipulation, validation, and modeling tasks.
• Ensures integrity, consistency, and scalability of configuration design,…