Health Plan Network Adequacy Analyst III

Job Summary:

The Health Plan Network Adequacy Analyst III reviews and analyzes the effectiveness and efficiency of existing market operation processes and systems, ensures compliance of State and Federal Network Adequacy Standards, and participates in development of solutions to improve or further leverage these functions.

Essential Functions:

• Manage new and ongoing market network adequacy initiatives from concept to implementation and provide statistics measuring progress throughout.
• Perform cost-benefit and return on investment analyses for proposed initiatives to aid in the decision-making process; collect and analyze data in support of business case creation and realization.
• Ensure operational effectiveness by assisting in the development of strategic plans for provider contracts, network adequacy, and network performance, including business, financial, and operational goals and objectives; recognize and manage scope and expected outcomes across the Market to HPLC’s strategic initiatives and process improvements.
• Coordinate with Corporate business areas to conduct network surveys, data, reporting and analysis of all network adequacy standards to include measuring geographic standards, time and distance standards, appointment wait time standards, LTSS standards, and active provider standards.
• Develop oversight and monitoring processes to include identifying gaps, corrective action and executing upon remediation plans to ensure we comply with all adequacy requirements.
• Represent and interface as point of contact with regulators as the Network Adequacy Standards Subject Matter Expert to include but not limited to these state agencies: State of Nevada Medicaid, Nevada Health Authority, Department of Insurance.
• Assist in the review of reports and data for pattern identification, special cause variation identification, trend analysis, or other techniques; prepare and deliver summaries, recommendations, or alternatives of the analyzed information.
• Work closely with member experience/engagement workgroups and business areas to gather/attain data (to include but not limited to access related grievances and complaints, member calls, out of network claims data), conduct analysis and trends to develop remediation and corrective action plans.
• Develop, document and perform testing and validation as needed.
• Challenge the standard thinking with new ideas, approaches, and solutions which focus on process improvement and growth.
• Perform any other job duties as requested.

Education and Experience:

• Bachelor’s degree in Healthcare, Health Administration, Public Health, Business, Finance, Economics or related field or equivalent years of relevant work experience is required
• Minimum of five (5) years of experience in managed healthcare, network management or reporting, to include a minimum of three (3) years of health care operations, provider network adequacy, or project management experience is required
• Experience with provider data repositories and directories preferred

Competencies, Knowledge and Skills:

• Advanced proficiency in Microsoft Office Suite to include Word, Excel, Access and PowerPoint
• Familiar with a variety of analysis concepts, practices and procedures
• Excellent written and verbal communication, facilitation and presentation skills
• Strong interpersonal skills and high level of professionalism
• Effective listening and critical thinking skills
• Effective problem-solving skills with attention to detail
• Ability to work independently and within a team
• Strong analytical skills
• Ability to create and maintain excellent working relationships
• Time management skills, ability to develop, prioritize and accomplish goals with a sense of urgency
• Ability to effectively interact with all levels of management within the organization and across multiple organizational layers
• Ability to multi-task and remain flexible during organizational and/or business changes

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for long periods of time
• May be required to travel occasionally

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.