Provider Network Analyst

Job Description

Job Description

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

· Strive to apply an equity
lens to all our work.

· Reduce health disparities.

· Become an anti-racist organization.

· Create an equitable
work environment.

About the Role

This position is responsible for provider network performance analysis, development of provider monitoring of network data elements and standards to ensure network capacity, to include Behavioral Health provider access. The role partners with cross functional teams to deliver insights that support network strategy.

To be successful in this role, you:

• Have a bachelor’s degree in a related field or an equivalent combination of education and highly relevant experience, required.
• Have a minimum of three (3) years’ experience working with health care professionals.
• Have a minimum of three (3) years’ experience in managed care, required.
• Have knowledge of Centers for Medicare & Medicaid Services (CMS), Healthcare Authority (HCA), Office of the Insurance Commissioner (OIC) Washington State managed care network regulatory requirements.
• Have a minimum of two (2) years of experience managing large amounts of complex data and reconciling data output.
• Have experience in project coordination and office support, preferred.

Essential functions and Roles and Responsibilities:

• Leads network performance analytics, including KPI trend analysis, network access and adequacy analysis, and identification of network gaps and improvement opportunities.
• Develops and maintains model to assess and monitor Community Health Plan network performance and development strategies, ensuring alignment with organizational goals.
• Collaborates with subject matter experts to track key performance indicators, identify trends and recommend interventions for network improvement.
• Analyzes demographic and utilization data, providing insights to support regulatory filings and identify opportunities for network expansion.
• Monitor Medicare network to identify access and gap issues and provide analysis for resolution in support of monthly reporting and annual CMS network and exception process submissions.
• Maintains plan HSD tables and monthly Medicare reporting according to CMS standards, researching data discrepancies to correct identified issues when applicable.
• Responsible for submission of Provider Network Form A Certification letter to the OIC, to include monitoring files being available for auto-submission by IT.
• Collaborate on contracting provider data gaps to ensure reliability, completeness, and consistency.
• Analyzes Behavioral Health network and outreach in support of Quarterly HCA Provider Network Submission, to include regular review of geographic/service coverage of Behavioral Health Agencies.
• Supports Behavioral Health AADR process through data analysis and reporting, in alignment with contract department review.
• Develops Mental Health Assessment utilizing claims information and compilation of data sets to support analysis.
• Leads the creation and execution of process improvement strategies to optimize departmental systems and align performance with organizational objectives.
• Collaborates across departments and teams to initiate and deliver projects that advance network strategy and fosters interdepartmental partnerships.
• Supports the development of internal consulting capabilities for CHPW to strengthen delivery systems performance.
• Participate in cross-training with department analysts and program managers.
• Other duties as assigned.

Knowledge, Skills, and Abilities:

• Demonstrated excellent oral, written, interpersonal and analytical skills.
• Effective skills in data management accuracy, QA processes and ability to work with multiple and complex data sets on cross-systems.
• Ability to independently identify and analyze trends and initiate proactive interventions.
• Advanced proficiency with Windows software including Microsoft Word, Excel, and Access. Experience with SQL, Pivot Tables and PowerPoint preferred.
• In-depth knowledge of products and managed care operations.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Exempt and is not eligible for overtime. Based on market data, this position grade is 65 (see full range below) and has a 10% annual incentive target based on company, department, and individual performance goals.

CHPW offers the following benefits for Full and Part-time employees and their dependents:

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match
• Employee Assistance Program and Mental Fitness app
• Financial Coaching, Identity Theft Protection
• Time off including PTO accrual starting at 17 days per year.
• 40 hours Community Service volunteer time
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory* :

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical* :

• Extended periods of sitting, computer use, talking and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
• Frequent torso/back static position; occasional stooping, bending, and twisting.
• Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental :

• Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.