Provider Reimbursement & Network Services Analyst I/II/III

Univera Healthcare; Buffalo (NY); Hybrid; USD 62,400 - 106,929; Full time

Benefits offered by this job

Group health insurance

Retirement plan

Paid time off

Job summary

A health services firm in Buffalo is looking for a Network Services Analyst to analyze provider networks and develop payment methodologies. The ideal candidate will have strong analytical skills, proficiency in Microsoft Office, and a Bachelor’s degree in a relevant field. Responsibilities include negotiating claims and preparing financial reports. The compensation for the position ranges from $62,400 to $106,929 depending on experience and qualifications, with potential for remote work.

Qualifications

• Minimum four years of health-care experience in an analytical function.
• Ability to read and understand contractual language.
• Strong proficiency in Microsoft Office suite.

Responsibilities

• Analyzes and evaluates Health Plan provider networks.
• Develops consistent payment methodologies.
• Negotiates allowances for non-PAR claims.

Skills

Analytical skills

Written communication

Oral communication

Negotiation

Organizational skills

Education

Bachelor’s degree in Health Care Administration, Business, or Finance

Eight years of health-care/business experience

Tools

Microsoft Office suite

Job description

Overview

Job Description: Under the general direction of Assigned Management, a Network Services Analyst analyzes and evaluates the composition and characteristics of Health Plan provider networks. The role includes developing consistent payment methodologies and negotiating allowances for out‑of‑area/out‑of‑network non‑PAR claims.

In this capacity the analyst works closely with others to assemble and produce documentation and informational materials that guide senior management in making strategic network‑specific business decisions.

Essential Accountabilities – Level I

• Differentiates claim types and navigates various claims platforms.
• Uses pricing tools to optimize payment methodologies.
• Gathers data from multiple sources, updates and maintains it; prepares financial reports, statements and analyses for management review.
• Performs assigned analysis and assists in complex analysis for supervisory review, creates models and makes recommendations based on completed analysis.
• Assists in determining the impact of various business options for strategic planning and other financial decisions.
• Accumulates and evaluates data from outside sources to negotiate pricing for out‑of‑area/out‑of‑network services. Develops a letter of agreement and notifies the claims department that the service has been priced.
• Develops and analyzes supporting financial schedules, including preparation of worksheets, and maintains backup and documentation for internal control and auditing purposes.
• Supports and maintains contracting and relationship responsibilities for the utilization of Blue and non‑Blue national/regional provider networks, including development and maintenance of vendor contracts, tracking of open issues, and leading team efforts to manage network issues relative to prospective employer groups. Tracks status and reports for senior management.
• Creates and maintains network tracking reports by product and region, including threatened resignation reports, specialty inventory reporting, and provider‑specific product participation reporting. Assess analytics to identify potential network gaps and recommend changes.
• Supports product development initiatives such as development of networks to service Safety Net and Medicare products. Produces reports on products, network strategies, status, and financial information for negotiators.
• Consistently demonstrates high standards of integrity by supporting Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with corporate privacy policies and procedures.
• Exhibits regular and reliable attendance.
• Performs other functions as assigned by management.

Additional Accountabilities – Level II

• Works with larger, more complex, high‑visibility accounts that have been escalated. Develops and maintains more complex vendor contracts.
• Identifies root cause of problems; develops potential options and likely outcomes of each option; recommends the optimal option.
• Models the financial impact of changes to reimbursement methodology on an individual claim basis; articulates impact of switching from one methodology to an alternative.
• Analyzes, identifies, and recommends improvements to the claims process and inventories, such as triaging misrouted cases and conducting cost and quality analyses.
• Maintains appropriate backup and documentation to ensure regulatory compliance.
• Demonstrates adherence to internal controls surrounding regulatory compliance and explains them as required.

Additional Accountabilities – Level III

• Facilitates cross‑functional workgroups and internal meetings to present recommendations and lead workgroups in determining the best course of action for system or process improvement opportunities. Presents information clearly.
• Discusses complex out‑of‑network claims with providers and recommends solutions; tracks unusual and/or outstanding claims.
• Identifies trends and opportunities with network management/negotiators, presents findings and recommendations to management.
• Works with key stakeholders to create improvements either as a dedicated resource or within division processes to ensure end‑to‑end continuity.
• Analyzes and interprets complex records and documentation; reviews and assesses the validity of financial estimates from various sources against stated business objectives.
• Acts in a consultative capacity to management at all levels of the organization to provide professional technical expertise in determining suitable approaches to reimbursement concerns.
• Applies principles of total quality management, leads peer review activities consistently to identify and remove barriers to increased productivity, quality, cost effectiveness, and timeliness of operations and customer satisfaction.
• Designs and develops reports that illustrate integrated solutions to meet business needs or enhance performance.
• Reviews and approves project cost/benefit analyses prior to presentation to company management.
• Acts as a mentor to the team, striving to achieve high standards of professional competence and leading by example.

Minimum Qualifications – All Levels

• Bachelor’s degree in Health Care Administration, Business, Finance or a relevant field with a minimum of four years of health‑care experience in an analytical function, plus a minimum of one year of business‑user experience including negotiation, research, analysis and working with outside customers.
• In lieu of a degree, a minimum of eight years of health‑care/business experience in an analytical function, including a minimum of one year of business‑user experience including negotiation, research, analysis and working with outside customers.
• Ability to read and understand contractual language and negotiate on layman’s terms.
• Strong analytical, written and oral communication, organizational and time‑management skills.
• Proficiency in Microsoft Office suite.
• Ability to work with various levels of internal management and external audiences.

Qualifications – Level II (Additional to Level I)

• Minimum of five years of health‑care experience in an analytical function, plus a minimum of one year of business‑user experience including negotiation, research, analysis and working with outside customers.
• Excellent written and oral communications skills, strong organizational and time‑management skills.
• Strong skills in spreadsheets, databases, word processing and Microsoft Office products.
• Ability to present and communicate complex issues with fluency and expertise.
• Comfortable interacting with all levels of management.
• Relationship‑building skills.

Qualifications – Level III (Additional to Level II)

• Minimum of seven years of health‑care analytical experience, plus a minimum of two years of business‑user experience including negotiation, research, analysis and working with outside customers.
• Ability to identify trends and opportunities with network management/negotiators and present findings and recommendations.
• Demonstrated leadership, decision‑making and team‑building skills.
• Strong oral and written skills, plus excellent presentation skills.
• Certification preferred in Lean Six Sigma Green Belt.

Physical Requirements

• Use of computers and phone.
• Limited travel required.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Compensation Range(s)

Level I (E1 Pay Grade): Minimum $62,400 – Maximum $84,000
Level II (E2 Pay Grade): Minimum $62,400 – Maximum $96,081
Level III (E3 Pay Grade): Minimum $62,400 – Maximum $106,929

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget availability, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: The opportunity for remote work may be possible for all jobs posted by the Univera Healthcare Talent Acquisition team. This decision is made on a case‑by‑case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Equal Opportunity Employer