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Resp & Qualifications
The position is responsible for the company's end to end cost of care savings process to drive affordability and accessibility for CareFirst stakeholders including coordination and working with key matrix areas such as Finance in the development of a front-end data analytics strategy, target setting, ideation, vetting & selection, execution and post execution performance monitoring and measurement. Cost of Care will encompass end to end process accountability and the achievement of the company's cost of care goals, strategic direction for clinical innovation, and integration of the company's health services delivery system ecosystem. In addition, position is responsible for the P&L for CareCo (a professional services subsidiary company) and the strategic oversight of key clinical vendors management and vendor integrations.
Cost of Care Process Management
Oversees Cost of Care Management for CareFirst, which entails managing a cost of care process to achieve specific savings targets of approximately $150M of incremental year over year improvement to medical expense annually. Develops short and long-term strategies to drive affordability by coordinating cost of care efforts across the enterprise. Develops market intelligence to understand best practices in cost of care management, monitoring emerging trends among payer, physicians, hospitals, and ancillary providers. Drives analytics and insights to understand effectiveness of current practices and identify new opportunities to address the major drivers of health care expenditure. Responsible for collaborating with Provider Network / Value Based Care, Care Management (Utilization Management and Case Management), Pharmacy, Product / Benefit Design, and other business owners such as Payment Integrity, SIU, etc., to develop new ideas that drive savings opportunities. Prioritizes savings opportunities across the enterprise, assessing risks and benefits of each initiative and makes recommendations for investment in promising ideas. Works closely with FP&A in developing Cost of Care targets for each department and holding VPs and other leadership accountable for their respective department Cost of Care targets. Works closely with Strategy & Planning and FP&A on annual and multi-year planning process and participating in target development and business case planning. In addition, the role will drive implementation for cost of care initiatives. Supports business owners by leading them through standardized process to develop, execute, and monitor initiatives. Develops the monitoring system to understand effectiveness of individual projects and generate a Cost of Care reporting package to inform senior leadership. Leads governance for entirety of enterprise cost of care management processes and provides regular updates to P/L owners and Executive Leader Team. Builds a high-performing team to support cost of care management priorities; foster a culture of innovation and engagement to achieve the mission.
CareCo Profit & Loss Leader
Responsible for the P&L of the CareFirst subsidiary entity CareCo. This has responsibility for managing the financial performance of the organization. Oversees the P&L statements and performance of revenue, COGS, and operational expenses. Optimizes Case Management professional services for ASO accounts and brings a strategic suite of cost management (CF or white label) solutions to ASO accounts on a shared savings basis. Aligns with Sales on a strategic suite of cost management solutions with positive ROI and contributes to the CareFirst value proposition for its ASO customers. Oversees and manages performance of a suite of vendors that are performing professional services through CareCo. Responsible for the identification, contracting (in partnership with Procurement), implementation and ongoing execution and performance of high value clinical solutions/vendors that drive affordability for ASO customers. This will include heavy vendor oversight as further described below.
Cost of Care and Health Services analytics
Leads and oversees health plan's end to end cost of care process, including analysis of medical care cost and utilization data through a multi-disciplinary matrixed approach in partnership with the CFO. Identifies the drivers impacting cost of care, medical trend, and healthcare affordability. Leads the development of techniques and innovative solutions to effectively correct identified and anticipated underlying causes and contributing factors; close gaps in care; and ensure cost, quality, and member outcomes. Rationalizes the company’s care management ecosystem (clinical services, programs, and use of vendor solutions). Utilizes a data driven approach to create a roadmap of integrated solutions and interventions to address the continuum of healthcare needs, articulating the care model for what we do, how we choose to do it, and why we do it. Supports the Division and Company in telling our data / metrics driven value story in support of Sales, Customers and Members. Enables support for RFPs and Sales presentations across all business lines. As part of the responsibility for the company's end to end cost of care savings process, coordinates and works with key matrix areas such as Finance in the development of a front-end data analytics strategy, target setting, ideation, vetting & selection, execution and post execution performance monitoring and measurement. Leads a team of data analysts/scientists to produce effective support of the Health Services Division analytic needs. This includes medical expense tools; drill down including developing the population health analytics approach for healthcare services (machine learning / artificial intelligence); and data driven identification and stratification (ID & Strat) algorithm that supports the needs for all lines of business in connecting members with the right intervention across the continuum of care coordination and delivery.
Vendor management and integration
Oversees day to day clinical vendor relationships for key clinical and technology vendor partners, assessing and improving vendor performance, vendor operational reporting, maximizing the value and return on investment and decreasing cost within vendor relationships. Partners proactively with corporate vendor management to reduce risk, call out gaps and enforce SLAs, and influence vendor behavior as they deliver services to members and accounts on our behalf. Uses extensive technological knowledge to drive improved vendor integration, data exchanges, operational efficiencies, and performance improvement to drive improved return on investment (ROI).
This position manages people: 1-5 Direct Reports
Freedom to Act
Work is accomplished without considerable direction. Exercises judgment in selecting methods, techniques, and evaluation criteria in obtaining results. Exerts significant latitude in determining objectives of assignment. Takes calculated risks with consultation from the expert.
Problem Complexity and Problem Solving Timeframes
Works on complex issues where analysis of situations or data requires in-depth evaluation of variable factors. Constructs and may pursue alternative paths towards a solution. Exercises judgment in selecting method, techniques and evaluation criteria for obtaining results consistent with broadly defined policies and practices. Problem/Task resolution timeframe: Inclusive of shorter timeframes, but typically six to twelve months or more to resolve.
Level of Supervision Received
Establishes personal standards of performance within broad framework of policy and objectives as set by senior management.
Erroneous decisions or recommendations would normally result in failure to reach goals crucial to significant organizational objectives and would profoundly effect the image of the organization.
Contact with Others
Acts as prime consultant on significant tasks that affect the organization's long-term goals and objectives. Interacts with senior management and senior value-chain partners both internally and externally on matters requiring coordination and decision-making across organizational lines.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The
requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Bachelor's Degree
Education Details: Health Care Administration, Business Administration, Finance, Information Technology, or related field.
Experience: 12 years of progressive responsibility in a healthcare operational environment, with a minimum of 8 years of management experience.
In Lieu of Education
Previous experience within a health plan/payer organization, specifically driving cost of care saving processes.
Working knowledge of both commercial and government programs lines of business.
In depth knowledge of clinical operations and regulatory compliance related to care coordination in a payer organization.
Previous experience collaborating with formal health economics function within corporate environment
Knowledge, Skills and Abilities (KSAs)
Strong people management and leadership experience., Advanced
Ability to manage operations with an extensive and varied scope., Advanced
General understanding of health care claims data, trend analysis, and insurance operations and products., Advanced
Experience using data to make data driven business decisions., Advanced
A strong and influential communicator with experience in communicating across large teams including senior executives.,
Strong analytical skills with an ability to provide thoughtful impact analysis.,
Ability to articulate complex concepts into simple language.,
Experienced to lead and work within Agile, Waterfall, and/or Hybrid project models.,
Ability to leverage analytical, process, and program management skills to resolve issues.,
Strong critical thinking skills with the ability to exercise sound judgment and make solid recommendations, including formulating strategies followed by focused delivery and execution plans.,
Strategic agility and operational rigor. ,
Demonstrated successful planning and organizational skills in developing and implementing strategic and tactical plans.,
The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. 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: $224,000 - $336,000
Salary Range Disclaimer
Salary will be based on education, location, experience, certifications, etc. In addition to your salary, CareFirst offers benefits such as a comprehensive benefits package, incentive and recognition programs, and 401k contribution (all benefits are subject to eligibility requirements).
Department: (Executive Leader- Medical Affairs)
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 Federal health care programs.
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
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