Network Adequacy and Data Analyst - MidAtlantic Region

WORK LOCATION: Richmond or McLean, VA

Hybrid position - will require 3 days in the office

GENERAL DESCRIPTION

This position serves as an integral member of the Field Contracting Team.  This role is primarily responsible for monitoring and reporting on the network adequacy for the assigned market(s). This role also assists in developing the strategic direction and management of the alternative access product contracting activities for a given territory, including the configuration of new alternative access networks, maintaining existing alternative access networks and any reconfigurations of existing alternative access networks.  This position will be a subject matter expert on network adequacy as well as the criteria and intent for each alternative access product in the assigned market(s).  This position works in close collaboration with Compliance and Regulatory Reporting, Network Development & Competitive Insights, Network Solutions, Network Operations, Medical Economics, Provider Services, and Product. 

The position is active in both the evaluation of network adequacy and provider recruitment opportunities.  The role is also actively involved in network design opportunities and the network implementation / expansion.  The role will not be responsible for loading the network directly, but is responsible for ensuring the Contracting intent is translated correctly to Network Solutions and Network Operations, and ensuring that contract interpretation flows consistently to downstream processes. 

DUTIES AND RESPONSIBILITIES

• Manage network adequacy reporting analysis and validation processes during the phases of State filings as well as alternative network evaluation, implementation and filing. Responsible for monitoring network adequacy on an ongoing basis.  Actively participate in annual State re-filings, as required, to ensure consistency.

• Subject Matter Expert for all Alternative Access Products in assigned markets, including inclusion/exclusion criteria, anchor providers, network adequacy and differences between various alternative access products in assigned markets.

• Evaluate various network configuration alternatives and make informed recommendations to markets.  Includes, in part, acquiring information, analyzing, reporting, recommending, compiling, reviewing, and/or submitting data as required to ensure network meets established solution criteria.

• Works in partnership with Network Solutions to manage the end to end network build, reconfiguration or expansion (i.e. drive the creation of correct provider files based on criteria, analysis, reporting and decision making).

• Represent Contracting for updates and decision making for items delegated by the market

• Translates the intent of the delivery system criteria as it relates to network configuration, works with other areas to resolve discrepancies and ensures that it will be consistently applied across all tools and processes.

• Coordinate with matrix partners in Network Solutions and Compliance to ensure appropriate submissions.  Coordinates discussion regarding any overlap and variations between products and markets to ensure consistency.

• Conducts ongoing evaluation of network criteria to maintain quality control of the network construct.  Provides recommendations for issue resolution.

• Responsible for coordinating market sign off of data loading files during product and network implementation.

• As part of end to end implementation management, ensure critical timelines are consistently met.  Proactively provide input on maintenance requirements during implementation planning.  

• Understand Federal and State regulatory requirements, especially as they relate to market suppression, providers accepting new patients, and the requirements for network adequacy, communicating with Compliance to obtain guidance.

• Interacts with Compliance to support requirements for filing processes, which may include development, evaluation, formatting and reporting of information to regulatory bodies.

• Manages the LocalPlus product data validation and clean-up process for aligned market(s) by running reports, summarizing results, assigning needed research to Provider Services, getting needed approvals from Contracting and submitting for loading/correction.

• Proactively provide feedback to National Network Access Lead on issues, training, areas of confusion, inconsistencies and recommendations related to the role

• Ensures that communications are issued on network HCP changes per established processes.

• Participates in the development of internal training and documentation updates, as required.

• Works collaboratively with resources within the region, other region