Resp & Qualifications
We are looking for an experienced people leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and at last two days a week at a CareFirst location based on business needs and work activities/deliverables that week.
This role is responsible for managing the ongoing adequacy and competitiveness of the CareFirst provider networks. The emphasis is on competitive market positioning and assuring our networks allow for the appropriate access to healthcare services in accordance with the CareFirst mission. This includes but is not limited to: formulation of contracting and reimbursement policy and strategy, negotiating legacy fee-for-service reimbursement terms, compliance with all network adequacy standards and contractual regulatory requirements, expanding the breadth and depth of CareFirst Value Based Agreements and implementation of new innovative networks and/or network innovation to support growth and expansion to new markets.
- Directs and controls departmental functions associated with the process of negotiation and maintenance of professional, ancillary, behavioral and institutional contracts (including DC and VA hospital contracts) for all lines of business in the service area. This includes negotiating, financial analysis and quantification, networks impact, qualification and competitive analysis, and implementing all non-standard contracts. Developing, implementing, recruiting, and overseeing network adequacy to assure networks that meet both regulatory and marketability requirements. Assessing business opportunities and activity participating in the design of future corporate wide initiatives and product offerings. Ensuring contracting unit cost increases are within established budget, and accurate/timely reporting to finance department. Developing competitive intelligence tools to formulate recommendations and provide basis for decision-making. Developing business cases and presentations for Executive Management; and facilitating corporate and divisional projects specifically tied to contracting initiatives. Supporting sales department requests in existing networks to assure overall competitiveness and accessibility of the CareFirst networks.
- Oversee management team that leads contracting and payment-transformation teams as well as the individual team members including hospital and behavioral health areas of focus. Support development of team members through mentoring, coaching, and performance management where necessary.
- Responsible for the development, planning and implementation of cost-of-care initiatives such as new innovative networks and/or network methodologies in accordance with the Network Road Map and in line with achieving the corporate goals and strategies. This includes leading cross functional Health Services work groups as well as representing provider contracting in enterprise-wide work groups to assure alignment with both departmental and corporate initiatives.
- Directs, plans, manages, and controls the operations and activities of the Payment Transformation department for all regions and lines of business. This includes but not limited to development and maintenance of the CareFirst value-based programs. Serves as the primary negotiator for value-based negotiations with large health systems, select clinically integrated networks, and select large practice aggregators, and oversees staff who manages value-based negotiations with all other providers.
- Oversees corporate policies with regard to provider contracts, reimbursement methodologies, fee levels, and provider notifications of such policies. Serves as corporate expert for the development, implementation and ongoing management of reimbursement policies.
This position manages people.
Education Level: Bachelor's Degree in Business, Healthcare Administration, Finance, or related discipline OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
- 8 years' experience with increasing responsibility in a healthcare environment or related industry including 5 years experience with provider contracting, negotiation and reimbursement development; provider relations and recruitment; and/or network development.
- 3 years direct management experience.
- Advance Degree- MBA or HealthCare Administration.
- 3 years experience in Government Programs network development, adequacy and compliance.
- Experience with DRG contracts and reimbursement systems.
Knowledge, Skills and Abilities (KSAs)
- Possess a thorough understanding of hospital and health care contracts and reimbursement methodologies as well as national reimbursement mechanisms such as DRGs, CPT, HCPCS, ICD-9, AB and CMS-1500.
- Ability to analyze contractual agreements and an understanding of data processing functions and system interfaces.
- Deep understanding of health care marketplace dynamics.
- Understanding of local payer, reimbursement and access and provider landscape.
- Strong understanding of insurance and benefit design with both commercial and government payers.
- Strong oral and written communications skills are required, to communicate effectively with all levels of management, customer areas, and peers.
- Basic understanding of the strategic and financial goals of a health care system or payer organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits).
- Deep understanding of multiple reimbursement methodologies used in healthcare provider contracting.
- Strong strategic thinking and a desire to consistently uncover opportunities for improvement.
- Working knowledge of provider community, market and its underlying financial dynamics.
- Strong process facilitation, problem solving and analytical thinking abilities to make sound business decisions on a day-to-day basis.
- Exceptional strategic and problem-solving skills to effectively influence key business decisions.
- Ability to toggle between strategic and detail orientated thinking.
- 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: $136,000 - $252,450
Estimate Amount: 10%-day travel to provider offices within the CF service area on an as needed basis.
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
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