Resp & Qualifications
The Sr. Wellness Operations Analyst functions within a dynamic division charged with improving the quality and experience of care while reducing cost via a continuum of care support programs. The incumbent supports the successful implementation and ongoing operations on a day to day basis of Wellness and Disease Management program that service CareFirst full insured and self funded individual and group members. He/she serves as primary organizational liaison with external vendor partners and managing the contractual relationship. Maintains a reporting system on the program’s operational, clinical and cost of care metrics reviewed regularly by senior leadership. Shepherds the measurement and assessment process with Health Economics and other internal stakeholders to enable increased visibility of programmatic impact.
Responsible for execution/delivery of projects within the Wellness and Disease Management program. Coordinates and is responsible for day–to-day implementation, vendor management, coordination with SBUs and closely coordinates with management of other clinical programs. Ensures alignment with the overall corporate vision and goals by focusing on compliance, procedures and monitoring/control to achieve program goals. Works closely with the Division’s clinical leadership on the design, implementation and oversight of the program. Presents program updates to leadership on a routine basis.
ESSENTIAL DUTIES AND RESPONSIBILITIES include, but are not limited to, the following:
Responsible for supporting the design, implementation, and operations the Wellness and Disease Management Program, ensuring smooth operations between CareFirst and the vendor partner(s). Serves as primary operational liaison with vendor partner(s); manages the contractual relationship including pricing, performance, contract terms, service level agreements and other key elements.
• Participates in and supports the process of contracting, rate negotiations with vendors.
• Coordinates all go-live activities to ensure that all parties are supported and assisted.
o Ensures efficient and high-quality installation of new programs and services and monitors all aspects of implementing projects.
o Lead for tracking, analyzing and ensuring resolution of system and/or process-based issues in the initial go-live phase.
• Trouble shoots barriers that limit program impacts, including day-to-day and systemic issues. Ensures that vendor partner(s) provides services in accordance with services level agreements.
o Addresses escalated service issues, including support of onsite face to face meetings with executives to ensure the vendor partner(s) resolves ongoing issues in acceptable long-term solutions.
o Participates in regular meetings with vendor partner(s) to manage issue escalation, new program development and enhancements.
• Supports Monthly Wellness and Disease Management Program Vendor(s) Invoice Process
o Coordinate monthly invoices, this includes auditing, approving, recording and payment of all the invoices for services that are paid thru CARE. Submit each individual invoice thru Oracle for payment. Forward all paid invoices to Finance for entry into General Ledger. Track and enter all invoice payments into the Master Wellness Account spreadsheet. Act as liaison between vendors and Accounts Payable to verify payments or location of missing payments & checks.
o Tracks and reports on the financial aspects of the Program.
o Performs Annual Medical Loss Ratio reporting
o Monitors claims payment activities and works with the appropriate business leaders across the organization to ensure resolution of escalated claims issues.
o Works with vendor partner(s) and internal business units to ensure program claims are accurately submitted and processed.
• Oversees and evaluates the Wellness and Disease Management Program, policies and procedures to ensure compliance with all Federal/State/DC regulations and external accreditation standards pertaining to or affecting health care systems.
o Maintains full quality accreditation through NCQA with submission of all necessary documentation.
o Ensures compliance to current FEP PPO Guidelines for Disease Management Program and provide update to their annual Business Plan.
o Actively participates in account-specific audits.
Participates in the design, implementation and maintenance of an analytic infrastructure to manage vendor partner performance, evaluate the impact of the Wellness and Disease Management program, and communicates a compelling value story to members and accounts.
• Participates in the design and implementation of reporting on the program’s operational and engagement metrics, clinical outcomes and cost of care for members and accounts, in collaboration with the Health Economics team.
• Evaluates and interprets complex program data to identify gaps in performance and identify opportunities for program optimization.
• Ensures that reporting supports management of vendor partner performance, including adherence to program guidelines, service level agreement, performance guarantees and/or other contractual obligations.
• Prepares quarterly performance summaries.
Performs the high-level tasks associated with general Program Management. Collaborates daily with Wellness Consultants and other internal stakeholders from Marketing, Commercial Markets, Government Programs, Corporate Development, and the Division’s internal Care Support and Health Economics teams for the purpose of managing the Wellness and Disease Management Program.
• Supports all aspects of Program, which may include conducting cost benefit analysis, developing work plans, monitoring of vendor service level agreements, designing policies and procedures, developing workflows, and implementing business and system monitors and controls.
• Provides both verbal and written communications regarding Program status, risks, issues, and risk mitigation plans. Makes recommendations on program decisions to leadership.
• Develops and maintains “lessons-learned” inputs for utilization on future projects.
• Coordinates the resolution of resource, budgeting, change, and legal issues affecting the Program. Supports the full project management life cycle for the implementation of highly complex, large scale, strategic clinical programs initiatives.
• Implements policies, work flows, business and system monitors and controls to ensure the successful management and reporting of the majority of the clinical programs utilized by all care management and care coordination areas across Medical Affairs.
• Bachelor’s degree in a health, wellness, or business-related field; in lieu of a Bachelor’s degree, must have 4 years related work experience.
Department: TCCI Oversight
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 apply before: 1/23/2019
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 physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee 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 employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Must be able to drive independently to vendor locations for site visits and/or business meetings.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship