CareFirst Careers

Provider Incentive Administration Manager

Resp & Qualifications

PURPOSE:  CareFirst has corporate goals to transition from paying fee-for-service to value-based contracts. The primary function of this position is to plan, direct and control the following activities: provider finance in value-based contracts; develop and support measurement criteria in contracts; run reporting related to provider reimbursement and reconciliation; make arrangements for quarterly incentive payouts.

This position reports directly to the Vice President of Practice and Payment Transformation.  The incumbent is responsible for the formulation of CareFirst policy and strategy with respect to provider and system financing to administer financial incentive payout and loss collection. The incumbent will be required to understand contracts, measurement criteria, run reports, deal with exclusions/exceptions, make arrangements for payouts that are auditable and ultimately routinized. This position will work closely with Provider Contracting Accounts Payable, and Actuarial departments.

Under the general supervision of the Vice President of Practice and Payment Transformation the incumbent’s accountabilities may include, but are not limited to, the following:

  1. Design, implement and maintain oversight of value-based payment management (based on contract), including actual quarterly incentive payments, reconciliation, and reporting. Operationalize value-based incentive payments with the proportionate share traceable back to each self-funded plan sponsor, CareFirst risk pool or government program. Conduct reporting to confirm earned incentive payment is valid and accurate. Develop and validate quarterly payout. Manage incentive payout or risk paybacks of incentive-based contracts.  Develop and maintain quarterly reporting tracking gross and net savings generated from value-based agreements.
  2. Through deep understanding of value-based contract methodologies and incentive structures, oversee collaboration with Value Based Payment team and Networks Management team to design, build, implement, and routinize incentive structures. Partner with IT and Finance to understand payment systems and optimize process/procedure for payment.
  3. Participate and support internal and external audit processes. This includes defining how to attribute per member per month payments to ASO accounts.
  4. Build, direct, coach and lead staff. Responsible for all managerial duties associated with position; direction and vision for policy and quality standards for all departmental work; Associate action plans; tactical planning, implementation, monitoring and reporting; budget and expense planning; ad hoc executive management reporting.
  5. Develop processes to assure that Providers in value-based agreements are following through on expected behaviors and collaborate with the Office of General Counsel and Network Contracting to develop processes which assure timely notices of breach of contract to Providers who fail to meet obligations in their value-based contract agreements. 

Required Education/Experience/Skills/Abilities:
• Bachelors degree in business or finance.
• Must have a minimum of 5-7 years’ experience in the health care industry and at least 3 years of increasing responsibility in a management position. 
• Proven ability to build and lead a team, providing coaching and development and ensuring alignment of skills and knowledge with business needs.
• Possess a thorough understanding of hospital and health care contracts and reimbursement methodologies, value based contracting methodologies and contract compliance, and fee-for service payment management.
• Possess a broad understanding of revenue cycle management and claims adjudication.
• Must demonstrate resilience and 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.

• Previous managed care, State and/or Federal health care programs (i.e., Medicaid, Medicare) or health insurance payor industry experience.
• Healthcare operations experience
• Experience in administration of Medicare/Medicaid health plans
• Knowledge of Maryland’s regulated hospital rate setting system
• MBA or CPA


Value Based 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:

Closing Date

Please apply before: 09/13/2019

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 of 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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