Mgr, Medical Cost Mgmt

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

Responsible for managing multiple aspects of the Enterprise medical costs structure including both on-system and off-system medical costs and directly lead efforts across the Enterprise to provide and present meaningful medical cost trend analysis to drive opportunities and decision making. Collaborate with multiple Commercial and Government Program business partners, including both clinical and financial, to drive the Medical Cost Trend Committee with the goal of identifying emerging business trends and the development of medical cost action plans. Key focus areas will include directly managing the Government Programs payment cycle for various provider incentive programs and other value based payment programs including shared risk programs, ensuring that necessary internal controls are implemented and working effectively and Government value based programs are administered within financial expectations, leading the Medical Cost Trend Committee, developing the underlying assumptions and business commitments to support all medical cost budgeting and forecasting activities, and for the financial oversight of the Enterprises Behavioral Health Program.

Responsibilities:

• Direct and drive the Enterprise Medical Cost Trend Committee process and partner with leaders across Analytics, Network, Medical Policy, Clinical Operations and Value Based Programs to review and identify emerging business trends and to collaboratively develop solutions to mitigate trend.

• Partner with the Enterprise Behavioral Health owner to drive financial performance through vendor management, new and existing program design and evaluation, advanced analytics and reporting, network financial management and medical cost action plans. Responsibilities include budgeting, forecasting, operations finance, development of analytics and strategic investment.

• Direct and support HCM&T initiatives throughout the Enterprise related to network initiatives and optimization, medical cost action plan development and validation, vendor return-on-investment evaluation, and value based program evolution and risk transfer.

• Develop the monthly Commercial & Medicare Network Unit Price Model reporting and collaborate with the HCM Network team on identifying drivers of network unit price and the development of network strategic initiatives.

• Own the development, production and continued enhancement of HCM&Ts Monthly Operating Report and partners across the enterprise to report, track and challenge HCM business metrics in order to meet our P&L objectives.

• Direct activities amongst HCM&T partners, Actuary and Finance to develop and validate medical cost trend reporting for the Enterprise budget and forecasting purposes.

• Lead the ownership and credibility for all Incentive and Value Based Program financial, payment and analytical processes for Horizon's Government Programs Division including providing strategic oversight for critical business and technological aspects of the implementation and ongoing administration of these payment processes.

• Lead the analysis and business case development for Horizons Government Programs Divisions Incentive and Value Based contracting arrangements and evaluate the business terms of agreements in support of the negotiation of rates with providers.

• Direct the development of Government Programs value based models to promote the transition of providers into shared savings models and ultimately migrate into shared risk models.

• Manage the Government Programs Value Based Programs reporting for both internal and external customers including the issuance of monthly, quarterly and annual value based reports and payments.

• Identify opportunities to reduce manual processes and interventions and develop systemic solutions to drive efficiency. Accountable for maintaining effective internal controls over the processes and transactions under areas of responsibility including the completeness and accuracy of financial information and transactions, compliance with applicable laws and regulations, and the effectiveness and efficiency of operations.

• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers staff salaries.

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

• High School Diploma/GED required.

• Bachelor degree in finance, accounting, business administration preferred or relevant experience in lieu of degree.

• Requires a minimum of eight (8) years experience in managed health care industry.

• Requires a minimum of five (5) years of analytical/financial experience.

• Requires a successful track record in leading cross functional teams in large, multifaceted initiatives across an organization.

• Requires experience with action plan development and monitoring.

• Requires health insurance industry, including product and insurance, terminology as well as health plan operations.

Additional licensing, certifications, registrations:

• A valid drivers license and access to a car.

Knowledge:

• Contracting concepts and various provider reimbursement methodologies.

• Regulatory environment, state specific laws, mandates and regulations

• Incentive and value based contracting concepts.

• New Jersey hospital and physician community.

• Knowledge of data processing concepts and related applications including, but not limited to Microsoft Access, SAS and SQL is preferred but not required.

• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, Access and PowerPoint) and Outlook.

Skills and Abilities:

• Requires excellent management, organizational and leadership skills.

• Requires excellent oral and written communication skills.

• Requires excellent problem solving skills.

• Requires excellent presentation skills.

• Requires excellent analytical skills.

• Requires excellent delegation and project management skills.

• Requires the ability to work in a production focused environment.

• Requires management experience with a focus on customer service, goal setting and coaching.

Travel:

• Minimal travel required.

Salary Range:

$106,400 - $145,215

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.