Senior Provider Network Analyst

Location

Fairfield, CA | United States

Job description

This position is responsible for being the primary lead for research and resolution of complex
provider data issues. Extracts, manipulates, analyzes, and evaluates accuracy of provider data for
regulatory reporting and new program implementations and ensures compliance with state and
federal regulatory requirements. Trains or facilitates training for learning how to use PR’s
provider data system, reconciling discrepancies, preparing regulatory and internal reports and
understanding the provider network. Serves as the provider data steward assisting the
Information Technology department and others in defining report specifications and building
programs. Oversees and/or completes projects with high complexity and assists other staff with
day-to-day operational activities. Coordinates and/or completes projects with medium to high
complexity. Participates in complex interdepartmental initiatives.

• Leads and supports provider network analysis and reporting.
• Uses data to perform gap analyses to support network access and expansion plans.
• Produces or oversees the accuracy and timely submission of regulatory reports.
• Liaison with the Claims, Finance, IT, and Compliance departments providing support and
  collaboration to ensure accurate provider data in systems and for reports.
• Leads regulatory reporting, responds to regulatory inquiries and audit findings related to
  provider network and oversees the successful completion of the Annual Network and
  Subcontracted Network Certifications.
• Drafts responses to findings and inquiries from regulators and conducts root cause
  analyses of any identified deficiencies.
• Serves as subject matter expert for provider data required for accurate integration into
  PHC’s claims system.
• Coaches team members by answering questions and providing ongoing education to
  support successful completion of day-to-day activities and continued learning.
• Monitors inventory daily, assign time sensitive priority work to staff ensure maintenance
  of timeliness standards. Recommends and implements plans to address backlog.
• Develops and executes training plans and guides, including design of content for LMS
  courses regarding the provider network and the provider data system.
• Drafts operational procedures and trains staff in developing ad hoc reports and regulatory
  reports.
• Ensures trainees receive scheduled training and move along the training continuum.
• Leads implementation of new processes, programs and system testing and training
  upgrades.
• Attends internal and external meetings on behalf of the department and participates in, or
  recommends solutions to issues.
• Participates in interdepartmental initiatives, documenting follow-up assignments and
  keeping department management informed of project progress and challenges.

Secondary Duties and Responsibilities

• Provides back-up to Manager responding to complex inquiries from other departments or
  external customers.
• Conducts ACD call monitoring, documenting opportunities for individual and/or
  department training. Provides input for performance evaluations.
• Other duties as assigned.

Bachelor’s degree and a minimum five (5) years healthcare experience,
preferably in a Medi-Cal or managed care environment; or equivalent
combination of education and experience. Experience with data
stewardship, network analysis and regulatory reporting required.

Excellent analytical skills to resolve complex policy and technical
problems and make recommendations for action. Ability to present
statistical and technical data in a clear and understandable manner.
Ability to interpret and analyze regulatory standards and guidelines and
act as a technical resource to explain them. Skill in coaching and
leading others. Excellent interpersonal and time management skills.
Advanced computer skills, including proficiency in multiple software
applications including Microsoft Office (Word and Excel). Experience
with managed care database applications; Strong organizational and
multi-tasking skills.

Excellent oral and written communication skills. Project management
skills. Ability to use good judgment in making decisions within scope
of authority to handle sensitive issues with tact and diplomacy. Ability
to facilitate meetings, build consensus with individuals at all levels and
assist with development and implementation of major initiatives.

More than 50% of work time is spent using a computer. Ability to lift,
carry or move objects of varying size, weighing up to 25 pounds.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$ 79,273.96 - $ 103,055.85

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Job tags

Salary