[Hiring] Director of Provider Analytics @WellSense Health Plan

Role Description

The Director of Provider Analytics reports to the Chief Actuary and leads analytics supporting provider contracting, provider performance, network strategy, and network adequacy. This role is responsible for translating provider, claims, membership, and network data into actionable insights that support:

• Contracting decisions
• Network development
• Regulatory compliance
• Broader business strategy

The Director also oversees network adequacy analysis, monitoring, and regulatory reporting using Quest software, ensuring provider networks meet applicable access and adequacy requirements and proactively identifying potential network gaps.

Qualifications

• Bachelor’s degree in actuarial science, mathematics, statistics, economics, finance, data science, healthcare administration, or a related quantitative discipline
• Master’s degree preferred
• 8+ years of progressively responsible experience in health insurance analytics, medical economics, actuarial analysis, provider analytics, network analytics, or related functions
• Successful completion of pre-employment background check

Requirements

• Strong knowledge of healthcare claims, provider reimbursement, utilization, and medical cost analysis
• Experience with provider network adequacy analysis and regulatory reporting
• Experience supporting Commercial/ACA, Medicaid, Medicare, or multiple lines of business
• Experience with Quest network adequacy software, or comparable network adequacy/geospatial analytics platforms
• Ability to use well-developed interpersonal skills to lead and direct the efforts of others, both internally and externally
• Proficiency in MS Office, and data query programs such as SAS/SQL
• Strong project management skills
• Strong communications and negotiation skills, both verbal and written

Benefits

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities

• Provider Analytics & Contracting Support
  • Lead analytics supporting provider contracting, reimbursement strategy, and provider negotiations
  • Develop financial models to evaluate reimbursement proposals, contract terms, and alternative negotiation scenarios
  • Analyze provider utilization, reimbursement, referral patterns, and performance to identify key trends and opportunities
  • Assess provider reimbursement relative to internal and external benchmarks
  • Quantify the financial impact of proposed contract and network changes across products and markets
  • Provide Network Strategy leadership with clear, actionable insights to support contracting strategy and decision-making
  • Partner with Actuarial to evaluate the financial implications of significant provider contracting and network changes
• Network Adequacy, CHIA & Regulatory Reporting
  • Lead network adequacy analysis, monitoring, and reporting using Quest software
  • Oversee preparation, validation, and submission of required network adequacy reports
  • Assess provider accessibility and geographic coverage across specialties, facility types, products, and service areas
  • Identify network gaps and partner with Provider Network teams to develop appropriate remediation strategies
  • Proactively evaluate the impact of provider terminations, network changes, membership growth, geographic shifts, and new product or service area expansion on network adequacy
  • Lead or oversee CHIA data submission processes, including data preparation, validation, reconciliation, and timely submission in accordance with applicable requirements
  • Establish appropriate data quality controls and validation processes to ensure the accuracy, completeness, and consistency of CHIA submissions
  • Partner with internal stakeholders to investigate and resolve data quality issues, submission errors, and reporting discrepancies
  • Maintain strong analytical controls, documentation, and quality assurance processes to support accurate and auditable regulatory reporting
  • Serve as the organization's analytical subject matter expert for network adequacy, CHIA reporting, and related provider data
• Network Strategy & Optimization
  • Provide analytics supporting network development, provider recruitment, geographic expansion, and network optimization
  • Evaluate provider supply, geographic coverage, member access, referral patterns, and network concentration
  • Assess the potential membership, financial, access, and competitive implications of network changes
  • Identify opportunities to strengthen the provider network while balancing access, affordability, competitiveness, and regulatory requirements
  • Support the evaluation and development of high-performing, tiered, or differentiated provider networks
• Provider Performance & Strategic Analytics
  • Develop analytics and reporting to evaluate provider performance across cost, utilization, access, and other key measures
  • Identify meaningful variations in provider performance and translate findings into actionable business insights
  • Develop provider and network performance benchmarks, dashboards, and management reporting
  • Support enterprise initiatives requiring provider and network analytics
  • Identify emerging provider and network risks and opportunities and communicate findings to leadership
• Actuarial & Executive Partnership
  • Serve as a strategic analytical partner to the Chief Actuary, Provider Network leadership, Finance, Product, and other business leaders
  • Provide provider and network insights supporting actuarial pricing, forecasting, and strategic planning
  • Translate complex analytical findings into concise recommendations for senior leadership
  • Develop executive-level reporting highlighting significant provider contracting, network performance, and network adequacy developments
  • Support strategic evaluations of network and provider initiatives, including financial and membership implications
• Analytics Leadership & Team Development
  • Lead and develop a high-performing team responsible for provider and network analytics
  • Establish standards for analytical rigor, data validation, documentation, regulatory reporting, and quality control
  • Prioritize analytical resources based on strategic importance, regulatory requirements, and business impact
  • Improve analytical capabilities through automation, enhanced data infrastructure, visualization, and advanced analytics
  • Foster a consultative analytics culture focused on translating data into actionable business decisions

Supervision Exercised

• Provides supervision of 3-8 staff, might including manager(s)

Supervision Received

• Supervision and support is received weekly and as needed

Compensation Range

$138,500 - $201,000. This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.