Health Plan Network Adequacy Analyst III

Health Plan Network Adequacy Analyst III

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 :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

Compensation Range : $70,800.00 - $113,200.00

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) : Salary

Organization Level Competencies :

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 inclusive environment that welcomes and supports individuals of all backgrounds.