Job SummaryThe
Senior Provider Network Analyst serves as a subject-matter expert in provider network operations, data integrity, and configuration management. This role is responsible for conducting advanced research, complex analysis, and strategic problem-solving related to provider network issues. The incumbent provides expert support for new business initiatives, provider recruitment, managed care contracting, and the development of operational improvements that optimize network performance and plan compliance.
Key Responsibilities- Identifies systematic, procedural, and cross-functional issues by conducting advanced data analysis; independently initiates corrective actions and drives resolution across operational teams.
- Extracts, manipulates, audits, and validates large and complex provider data sets to ensure accuracy for new implementations, expansions, and enterprise initiatives.
- Serves as the escalation point for ensuring ongoing compliance with provider contracts, regulatory requirements, and plan policies, identifying gaps, and recommending corrective strategies.
- Performs sophisticated statistical and financial analysis to evaluate provider performance, cost impacts, reimbursement trends, and opportunities for process and system improvement.
- Utilizes provider contract maintenance software to design, develop, and optimize contract templates, fee schedules, and credentialing configurations with minimal oversight.
- Leads or co-leads configuration and testing efforts for new report development, system enhancements, and business requirements tied to provider network functions.
Configuration Responsibilities - Conducts advanced data mining and analytics to determine correct system configuration, demonstrating deep expertise in interpreting business rules, state requirements, and contract terms.
- Translates complex provider agreements, state and government programs, and policy requirements into accurate and scalable configuration parameters.
- Independently interprets, provider contracts related to fee schedules, reimbursement methodologies, and system tables for both issue resolution and new configuration builds.
- Leverages prior experience to research, triage, and resolve high-complexity claims/encounter issues, including pended claims, system defects, and reimbursement discrepancies.
- Manages fluctuating work volumes while prioritizing tasks to meet aggressive deadlines, supporting both operational and strategic needs of internal stakeholders.
Leadership and Responsibilities - Acts as subject matter expert (SME) for provider data integrity, configuration standards, reimbursement methodologies.
- Provides mentoring, coaching, and informal leadership to junior analysts, offering oversight on analytical methodologies, quality reviews, and configuration work.
- Serves as a lead analyst on cross-functional projects, representing the provider network area in enterprise initiatives and system upgrades.
Strategic and Analytical Responsibilities - Independently identifies trends, root causes, and systemic issues within provider data, claims processing, and reimbursement logic; recommends strategic solutions to leadership.
- Conducts impact analyses for regulatory changes, benefit updates, and contract modifications, presenting findings and recommendations to leadership.
- Develops advanced dashboards, scorecards, reporting tools, and analytic models to support provider network strategy, performance monitoring, and decision-making.
Advanced Technical Competencies - Use advanced Excel, or analytic tools to perform complex data manipulation, validation, and modeling tasks.
- Ensures integrity, consistency, and scalability of configuration design, adopting best practices and contributing to standards development.
Cross Functional Collaboration - Partners with Contracting, Claims, Regulatory, IT, and Network Management teams to ensure operational alignment and resolve high-impact issues.
- Serves as a key liaison for new business implementations, market expansions, and provider network readiness activities.
Knowledge, Skills & AbilitiesPatient Group Knowledge (Only applies to positions with direct patient contact)
The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.
Competency Statement
Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.
Common Duties and Responsibilities
(Essential duties common to all positions)
1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.
Education Bachelor's Degree
Work Schedule: Days
Status: Full Time Regular 1.0
Location: Northgate-400 Association Dr.
Location of Job: US:WV:Charleston
Talent Acquisition Specialist: Tamara B. Young
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