Mgr, Network & Physician Contracting

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us.

We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

Job Summary

Lead/support the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospital, and ancillary facilities across the payment spectrum. Work with the Director on the fee-for-service (FFS) and value-based payment contracting initiatives, collaborating with payment evolution team to introduce the appropriate updated payment models (whether FFS or value based) and provider experience team to meet provider expectations. Lead/support complex negotiations and/or contracting arrangements which require developing a sound business strategy for the financial and legal terms required for contracting initiatives.

Responsibilities

• Responsible to work with Medical Economics and Actuary Department to draft provider rate proposals that adhere to Horizon's unit cost trends and negotiate such proposals with hospital executives, physicians and ancillary providers directly.
• Manage all the regulatory, accreditation and enterprise network adequacy requirements to ensure Horizon's 3.7 million members have access to a broad network across all its lines of business.
• The manager will perform quarterly analyses of the provider network from a cost, coverage and growth perspective. Provide leadership in evaluating opportunities to expand or modify the network to meet the Enterprise goals.
• Manages budgeting and forecasting initiatives for product lines to network costs and provider contracts.
• Contributes to drafting hospital, professional and ancillary contract terms to ensure they conform with all regulatory, accreditation and enterprise requirements while advancing Horizon's strategic and business objectives.

Requirements

This manager should have a demonstrated track record of creating and developing and managing successful network contracting strategies, with experience negotiating contracts with healthcare providers. This manager will lead a team of specialists, and independent contributors. Excellent communication and leadership skills are needed as this manager will work with a range of stakeholders both internally and externally.

Key Responsibilities

• Manage 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.
• Manage and negotiate contracts in compliance with Horizon reimbursement standards, and other key controls.
• Assist and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
• Ensures accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider file maintenance requests, claims stops and new hospital implementation. Adjudication of technical inefficiencies as it relates to system wide claims, configuration, and provider mapping discrepancies.
• Conducts research, identify root cause analysis and work fall out reports causing operational deficiencies.
• Manages the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the core systems.
• Collaborates with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and enterprise requirements.
• Understands the Enterprise Strategic and Financial Plan.
• Understands Value Based Programs including the financial, quality and operational aspects.
• Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance 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.
• Manages the effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures.
• Understands the impact of provider contract provisions on claims payment accuracy and timeliness and presents solutions to minimize unnecessary deviation and supports auto-adjudication.
• Implements multi-million dollar medical cost savings by introducing innovative industry initiatives and programs.
• Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
• Collaborate across departments to ensure that provider services are aligned with the needs of members and the organization.
• Assist with keeping the provider network integrated with the organization's objectives.
• Provide management level leadership and support all of the contracting staff.
• Assist the team with skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals.
• Represent the organization at industry conferences, webinars, and other events. Ensures that Horizon is well-positioned to identify and capitalize on emerging trends and opportunities in Horizon's market.

Education / Experience

• High School Diploma/GED required.
• Bachelor degree preferred or relevant experience in lieu of degree in health or health care related field from an accredited college or university or relevant experience.
• Requires a minimum of 5 years demonstrated business experience in hospital and provider group finance and/or managed care network development.
• Requires a minimum of 5 years 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' experience in successfully leading cross-functional teams to achieve improvements.
• Requires a minimum of 5 years prior provider experience in Commercial, Medicare, Medicaid, and Value Based Programs is required.
• Requires a minimum of 3 years' experience in health care cost data analysis and technical document writing.
• Requires a minimum of 3 years supervisory experience and/or leading people by influence.

Skills / Abilities

• 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.

Knowledge

• 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.

Travel

• Requires moderate travel up to 60%.

Salary Range

• $109,600 - $149,625

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

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.

Equal Opportunity Employer

• 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.