This job posting is no longer active
Resp & Qualifications
This position is responsible for contracting and overseeing various components of the provider network and ensuring contracted ancillary or institutional providers (Providers) meet regulatory and accreditation requirements. In addition, support Contract Managers with maintenance of Vendor agreements. The position represents the organization to Providers assuring an ongoing positive business relationship. Responsibilities shall include, but not be limited to, contracting, implementation, monitoring and re-contracting as necessary and negotiation and execution of Non-participating Single Case agreements.
Under the general guidance of the Manager, the associate is/will:
1. Provider contracting, implementation, maintenance, monitoring and re-contracting for standard agreements and non-complex provider specific agreements as necessary for all select network providers as assigned
2. Negotiate, document and manage all Non-participating Single Case rate negotiations as requested by Medical Management. Obtain required approval from other Blue Plans to negotiate with a Provider outside of the CareFirst service area. Work with internal and external staff to complete negotiations and communicate the agreed upon rates to ensure appropriate claims payment. Obtain Senior Management approval for Non-participating Single Case rate negotiations that exceed 20% of our standard reimbursement. Monitor and track all Non-participating Single Case rate negotiations and provide management reports. Monitor and respond to all requests from other Blue Plans requesting the approval to negotiate Non-participating Single Case rate agreements with CareFirst participating network Providers.
3. Manage standard Provider relationship’s and assist Contract Managers with complex Provider relationships (e.g., DRG and per diem arrangements) including determining level of network participation, establishment of payment levels, evaluation of financial feasibility/performance, negotiation of agreements/terms and assure network adequacy for areas of responsibility for all lines of business.
4. Monitor credentialing for select CareFirst Providers according to the applicable accreditation requirement and assist in credentialing activities as necessary. Recommend providers for termination as appropriate and identity opportunities for performance improvement and/or for future financial savings.
5. Assist in the development of Standard Operating Procedures and Provider network strategies and if approved, develop and implement the approved network or strategy by sending out RFI’s, establishing Provider criteria and monitoring targeted Providers.
6. Work with internal and external audit staff to meet frequent regulatory/audit requests. Design, implement and monitor any required Plan of Action to address the needs of Provider’s and the department’s compliance with regulatory requirements. When necessary identify recovery opportunities and educate on complex reimbursement methodologies.
7. Responsible for ensuring Vendor and Provider contracts are consistent and compliant with federal, state and accrediting entity requirements. Coordinate with Legal regarding proposed contractual modifications necessary to meet regulatory compliance or accreditation requirements. Assure compliance with regulatory requirements and quality monitoring.
8. Assist and support Contract Managers with the maintenance of Vendor and Provider agreements and relationships.
Department: Institutional Contracting
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.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 4/23/18
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 physical demands described here are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
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 of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship