Network Adequacy Manager
About The Position
Under supervision, the Network Adequacy Manager is responsible for ensuring issuer compliance with federal and state network adequacy standards, including O.C.G.A. § 33‑20E‑1 et seq. and Centers for Medicare and Medicaid Services (CMS) requirements under 45 CFR 156.230. This role serves as the State of Georgia’s primary authority for network adequacy oversight for Qualified Health Plans (QHP) and off‑Exchange Affordable Care Act (ACA) compliant plans. Oversee analytical activities, supervises staff and vendor partners, ensures timely and accurate review cycles, identifies issuer performance trends, and provides recurring updates to leadership regarding compliance risks and statewide network sufficiency. Maintain expert-level knowledge of Georgia-specific network adequacy requirements and align guidance with Centers for Medicare and Medicaid Services (CMS) standards. Serve as the subject matter expert on federal and state network adequacy regulations, policies, methodologies, and performance metrics. Interpret Centers for Medicare and Medicaid Services (CMS), Notice of Benefit and Payment Parameters (NBPP), Final Letters to Issuers, NAIC guidance, and regulatory publications to assess statewide impacts. Review issuer network adequacy submissions and evaluate provider network sufficiency for on‑Exchange and off‑Exchange plans. Validate issuer justifications for provider network gaps and determine whether deficiencies reflect market constraints or inadequate recruitment. Produce quarterly and annual adequacy analyses, dashboards, and leadership briefings to identify statewide trends. Manage the work of assigned analysts responsible for adequacy reviews, compliance tracking, and issuer support. Oversee vendors providing analytical and technical services; validate dashboards, data outputs, and methodology enhancements. Coordinate with agency divisions, Centers for Medicare and Medicaid Services (CMS), National Association for Insurance Commissioners (NAIC), and external consultants to ensure operational alignment and timely certification review cycles. Draft, review, and approve issuer correspondence regarding deficiency notices, corrective action requirements, and compliance determinations. Establish annual Qualified Health Plans (QHP) certification timelines for adequacy submission review and align with Georgia Access program timelines. Monitor compliance status and resolution timelines for escalated issuer cases. Recommend enhancements to templates, procedures, policy guidance, and analytical approaches. Perform other duties as assigned.
Requirements
- Bachelor's degree in a related field from an accredited college or university and three (3) years in a managerial role in the area of assignment; or seven (7) years of experience in the area of assignment, including three (3) years in a managerial role; or one (1) year of experience required at the lower level Mgr 2, Regulatory Compliance (RCM051) or position equivalent.
Responsibilities
- Ensuring issuer compliance with federal and state network adequacy standards
- Serving as the State of Georgia’s primary authority for network adequacy oversight for Qualified Health Plans (QHP) and off‑Exchange Affordable Care Act (ACA) compliant plans
- Overseeing analytical activities
- Supervising staff and vendor partners
- Ensuring timely and accurate review cycles
- Identifying issuer performance trends
- Providing recurring updates to leadership regarding compliance risks and statewide network sufficiency
- Maintaining expert-level knowledge of Georgia-specific network adequacy requirements and aligning guidance with Centers for Medicare and Medicaid Services (CMS) standards
- Serving as the subject matter expert on federal and state network adequacy regulations, policies, methodologies, and performance metrics
- Interpreting Centers for Medicare and Medicaid Services (CMS), Notice of Benefit and Payment Parameters (NBPP), Final Letters to Issuers, NAIC guidance, and regulatory publications to assess statewide impacts
- Reviewing issuer network adequacy submissions and evaluating provider network sufficiency for on‑Exchange and off‑Exchange plans
- Validating issuer justifications for provider network gaps and determining whether deficiencies reflect market constraints or inadequate recruitment
- Producing quarterly and annual adequacy analyses, dashboards, and leadership briefings to identify statewide trends
- Managing the work of assigned analysts responsible for adequacy reviews, compliance tracking, and issuer support
- Overseeing vendors providing analytical and technical services
- Validating dashboards, data outputs, and methodology enhancements
- Coordinating with agency divisions, Centers for Medicare and Medicaid Services (CMS), National Association for Insurance Commissioners (NAIC), and external consultants to ensure operational alignment and timely certification review cycles
- Drafting, reviewing, and approving issuer correspondence regarding deficiency notices, corrective action requirements, and compliance determinations
- Establishing annual Qualified Health Plans (QHP) certification timelines for adequacy submission review and aligning with Georgia Access program timelines
- Monitoring compliance status and resolution timelines for escalated issuer cases
- Recommending enhancements to templates, procedures, policy guidance, and analytical approaches
- Performing other duties as assigned
Benefits
- Robust benefits package designed for every stage of your career
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What This Job Offers
Job Type
Full-time
Career Level
Manager
