Description
Resp & Qualifications

***Must Reside in the CareFirst Service area (MD-DC-VA)***

PURPOSE:
This role is responsible for the building, management, oversight and negotiation of Institutional, Ancillary, Vendor, Dental and Professional contracts as well as the contracting of more complex high-performance provider networks. Performs duties to coordinate and support all types of provider contracting in accordance with guidelines in order to maintain and enhance the provider network and to meet accessibility, quality and financial goals.

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ESSENTIAL FUNCTIONS:

Successfully negotiates cost effective, competitive and complex contracts in focused regions that will produce savings to clients. Ensures the economic details in the contracts meet the need of key stakeholders. Manages the provider contract including negotiations, level of network participation, rates, payment levels, reimbursement methodologies, financial feasibility, performance monitoring and assessment, language and network adequacy. This includes negotiations, credentialing, financial quantification, network impacts, qualification and competitive analyses, implementation and monitoring of all contracts. Monitor Vendor Performance Standards and coordinate approval and assessment of penalties when appropriate. Facilitate and manage the implementation process of the negotiated terms with the Reimbursement Implementation department as well as the Provider Information and Credentialing department.
Develop business cases and present findings to Senior Management to support reimbursement and contracting initiatives through statistical analysis, cost/benefit modeling and analysis. Develop and present business cases to support changes in network strategies including rates, payment methodologies and network configuration. Upon approval, develop and implement the network by sending out RFIs, establishing periodic financial targets, provider criteria for participation, contracts and amendments, renegotiate and manage targeted networks or institutions and gain consensus with other internal areas affected by network changes.
Educates provider and their staff about the value proposition. Collaborates with the payment transformation department to develop and establish value based arrangements, alternative rate arrangements and ACO arrangements.
Develop contracts in coordination with the Legal Department for any changes to standard contract templates. Work with Legal to develop and review any proposed language changes discussed with a provider. Ensure compliance with jurisdictional regulatory requirements and quality monitoring organizations (NCQA).
Builds and maintains high performance complex medical networks to support the needs of the market and our clients.
Participate in strategic project planning and positively contribute to strategic objectives for the department. Coordinate department activities to meet Corporate Project deliverables. Work with Quality Improvement, Legal, Care Management, Internal Audits and other departments to identify and support corporate initiatives (e.g., hospitalist, diabetes education, reduction of authorizations, reduction of claims appeals, etc.). Participate in internal and external committees and workgroups, to identify network improvements and areas of concern, implement resolutions and contribute to the implementation process of projects as it relates to institutional, ancillary, professional, dental and vendor contracting. Provide subject matter expertise on projects as needed. Also, represent division as the subject matter expert in support of BCBSA workgroups.
Performs the provider credentialing as assigned, and data maintenance processes based on department policy, procedure, and standards and guidelines as indicated by NCQA guidelines. Incumbents are responsible for: 1) ensuring accurate and timely credentialing and subsequent submission of provider information to support claims submission, 2) ensuring submission of information that assures accurate and timely data for systematic provider demographics, 3) performing as the point of contact for the contracted institutions, ancillary providers and vendors and 4) assisting providers in obtaining insurance, privileges and/or other required credentialing and practice elements
Work with Reimbursement Department to develop and monitor financial projections, including development of financial modeling tools and network metrics needed for ad hoc and recurring reports. Develop and Manage Request for Proposal process to evaluate, score and select Network Providers and /or Vendors in support of Corporate and Network initiatives.

QUALIFICATIONS:

Education Level: Bachelor's Degree, Business, Finance, Health Care Administration or related discipline OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 2 years healthcare, business- or job-related field. 1 year experience in contracting, provider recruitment and/or provider relations

Preferred Qualifications:
Masters degree in Business or Health Care Administration

Knowledge, Skills and Abilities (KSAs):
Deep understanding of multiple reimbursement methodologies used in healthcare provider contracting.
Proven ability to build strong collaborative business relationships.
Understanding of contractual documents and ability to effectively communicate terms to providers.,
Working knowledge of provider community, market and its underlying financial dynamics.
Ability to function as a subject matter expert for assigned networks; ability to learn and use electronic contract management system.
Effective negotiation skills.
Superior PC skills, including financial analysis and modeling.
Working knowledge of provider community, market and its underlying financial dynamics.
Working knowledge of health care financial matters and third-party payment methodologies.
Effective interpersonal skills in order to lead project teams towards goal attainment and ability to work independently and as part of a team.
Effective time and project management skills to be able to plan and monitor activities to ensure achievement of organizational goals.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $62,856 - $124,839

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Fee For Services Contracting

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.