Blue Cross NC
Health Insurance (Payers)
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Job Description
This role is responsible for developing and executing strategic provider engagement and network initiatives across a designated geographic region, with a focus on supporting Blue Cross NC Medicare Advantage products. The position serves as a key liaison to professional, institutional, and ancillary providers, ensuring compliance with negotiated agreements while fostering strong, collaborative relationships with provider organizations.What You'll Do
Support and implement a three-year plan representing:
Supporting metrics and tactical plans
Support the development and promote the implementation of new provider payment models and reimbursement methodologies for managed care programs and products. Conducts financial and other quantitative analysis to ensure agreements are implemented efficiently and correctly.
Analyzes the negotiated agreement to ensure implementation and reimbursement is completed accurately. Assists management with analysis and prioritization of areas of implementation and predict with reasonable accuracy expected financial results.
Support the development and make recommendations for effective formats for providing education and programs to the provider community. Mediums available include printed materials, verbal and written presentations, and web based formats.
Responsible for managing a strategy to schedule, plan and visit specific network providers to:
Present or reiterate the BCBSNC medical and/or administrative policies and procedures;
Address provider inquiries and concerns
Disseminate information
Address specific “non-compliance” issues with BCBSNC agreements and coordinate the required corrective action.
Support the development and execution of meaningful provider workshops and education events.
Support the development and execution of methods to gauge provider satisfaction with education staff, materials, and processes. Analyze and execute improvement plans.
Timely management of resolution of large-scale issues for key providers. Makes recommendations to BCBSNC leadership on process improvements to enhance provider partner relationships.
Identify, analyze and resolve complex high-dollar operational issues impacting professional, hospital, ambulatory surgical center, and ancillary providers. Use the appropriate Stakeholder Service Model to increase provider satisfaction and reduce administrative costs.
Identify opportunities to control medical expenses and deploy action plans to accomplish stakeholder-specific or regional medical expense goals.
Represent BCBSNC in critical stakeholder meetings to address stakeholder administrative inefficiencies and to ensure contractual compliance. Participate in negotiations with stakeholders as needed.
Assist in the analysis of all products, identify any deficiencies, and make recommendations for improvement.
Provide analysis and feedback for technologies, trends, best practices and service offerings to incorporate them into overall stakeholder business solutions.
Plan all on-site visits to stakeholders to educate on BCBSNC medical or administrative policies and procedures. Address stakeholder concerns and non-compliance contract/administrative issues. Coordinate the required corrective actions.
Partner with assigned stakeholders to understand their processes, procedures and systems as they relate to the way they conduct business with BCBSNC.
Develop and maintain extensive knowledge of key stakeholders and/or regional territories. Leverage knowledge base to forward Enterprise relationships with stakeholders.
Track stakeholder issues for root-cause analysis, escalation, and closure. Document issue resolution using issue resolution protocol.
Comply with state, federal and BCBSA regulations governing stakeholders and suggest implementation of any product, process or system modifications to ensure compliance.
What You Bring
Bachelor's degree or advanced degree (where required)
3+ years of experience in related field.
In lieu of degree, 5+ years of experience in related field.
Bonus Points
Proven Medicare Advantage (MA) experience or experience working within a managed care or health plan environment supporting MA products
Ability to educate and advise providers on Medicare Advantage processes, products, claims, and operational requirements.
Demonstrated provider-facing or customer service experience, with the ability to build strong cross functional relationships.
Strong communication skills, including the ability to effectively explain complex topics and deliver difficult messages professionally.
What You’ll Get
The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
Work-life balance, flexibility, and the autonomy to do great work
Medical, dental, and vision coverage along with numerous health and wellness programs
Parental leave and support plus adoption and surrogacy assistance
Career development programs and tuition reimbursement for continued education
401k match including an annual company contribution
Salary Range
At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
Skills
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JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: HR.Staffing@BCBSNC.com.
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