Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Job Summary:
This role will facilitate and lead negotiations with Horizons network of provider partners of over 32,000 professionals, 1,500 ancillary providers and 76 hospitals in our New Jersey, Pennsylvania and New York markets representing billions in spend. Negotiations will include but not limited to Hospitals, Physicians and Ancillary providers, including value based programs for all of Horizons medical lines of business including Commercial, Medicare, Medicaid, DSNP, MLTSS and Casualty services.Facilitate and lead network provider negotiations for Horizons medical lines of business, including Commercial, Medicare, Medicaid, DSNP, MLTSS and Casualty services.
Accountable for accurate implementation of contracts, including collaborating with other departments to assure contract and special arrangements are loaded correctly. Initiate and manage provider file maintenance requests, claims stops and new hospital implementation.
Review technical inefficiencies as it relates to system wide claims, configuration, and provider mapping discrepancies. Collaborates with other internal business partners to conduct research, identify root cause analysis and work fall out reports causing operational deficiencies.
Collaborate with Medical Economics and Actuary to prepare rate proposals for all lines of business.
Accountable for timely contract submission and loading. Interface with matrix partners for network implementation and maintenance of all lines of business. Coordination across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, DRG updates and contract storage.
Serves as the go-to with matrix partners to assure contract and special arrangement reporting, provider file maintenance requests, claims stops, and new hospital implementations are resolved.
Analyze contracts to identify and implement medical cost savings by introducing innovative industry initiatives and programs.
Accountable for the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the core systems.
Adhere to Horizon standard contract language and payment methodologies.
Collaborate with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and Enterprise requirements.
Contribute to the development and execution of the network contracting strategy, including methods to adopt value-based contracting for providers operating under fee-for-service models, minimize special arrangements, and align to enterprise affordability objectives.
Develop and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
Collaborate across departments to ensure that provider services are aligned with the needs of members and the organization.
Ensure the provider network is integrated with the organization’s objectives.
Serve the team with skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals.
Create materials that the organization could use at industry conferences, webinars and other events.
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.
High School Diploma/GED required.
Bachelor degree in business, finance, accounting, health administration preferred or relevant experience in lieu of degree.
Preferred Master’s degree in health or business.
Requires a minimum of 5 years of business experience in hospital finance and/or managed care network development.
Requires a minimum 5 years demonstrated experience in two or more with in-depth knowledge and understanding of contract finance and reimbursement methodologies including FFS, Medicare DRG and APC’s, Medicaid pricing, capitation, full risk, shared savings and incentive arrangements.
Requires a minimum of 5 years provider experience in Commercial, Medicare, Medicaid, and Value Based Programs.
Requires a minimum of 5 years’ experience in hospital finance and/or managed care network development.
Requires a minimum of 5 years’ experience in health care cost data analysis and technical document writing.
Understands the Enterprise Strategic and Financial Plan.
Understands the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
Understands Value Based Programs including the financial, quality and operational aspects.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint); Should be knowledgeable in the use of intranet and internet applications.
Requires knowledge of Principals of Health Care contracting.
Requires knowledge of health care industry or health insurance industry.
Requires knowledge of the hospital and physician communities in the state of New Jersey.
Requires knowledge of laws and regulations regulating insurance, HMO hospital and physician practice.
Requires knowledge of quality measurement approaches applied in measuring insurance, HMO, hospital and physician practice.
Demonstrates ability to create, develop, and maintain business relationships.
Proven analytical, business case and product design skills a must.
Proven ability to exercise sound judgment.
Proven ability to ask probing questions and obtain thorough and relevant information.
Must be detail oriented with strong organizational skills. Proven ability to follow detailed instructions is essential, along with proven problem-solving skills.
Demonstrates flexibility and adapts to multiple responsibilities encompassing multiple areas within the organization.
Must demonstrate the ability to effectively present information and respond to questions from groups of managers, clients, customers.
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
Moderate travel is required.
Salary Range:
$84,700 - $115,605This 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.
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