Resp & Qualifications
PURPOSE: This position reports to the Manager, Payment Transformation and is responsible for the CareFirst Value-Based contract creation, negotiation, reporting, and implementation within a spectrum of health systems including but not limited to hospitals, healthcare systems, multi-specialty practices, ancillary vendor partners, etc
This senior-level expert contributor role exists to implement, contract, execute, and monitor new models to finance health care for CareFirst Members. The incumbent will drive CareFirst’s effort to transition from a fee-for-service payment system which incents health care providers to generate volume to a payment approach that rewards providers for the value they create.
The incumbent will be part of CareFirst’s Payment and Practice Transformation team. The Payment Transformation Initiative consists of an internal team of experts focused on innovative and impactful payment models, specialty practice benchmarking and operations, clinical support, legal support, pharmacy support and government program practice readiness. This role will be responsible for contracting and implementing all value-based agreements.
• This position will be the Lead Negotiator managing the relationship with CareFirst’s dedicated provider contracting counsel to create thoughtful, innovative, measurable and enforceable contract terms to drive the provider performance and transformation we seek. Present new contracts to review contract terms and work with executive and physician leadership of practices and health systems through the implementation phase of these new value-based arrangements. Responsible to develop and gain approval from executive management for an annual negotiation strategy which includes parameters for rate increases, and support for any changes to reimbursement methodologies and/or key contractual terms.
• Develop materials to brief Provider organizations, current and prospective Accounts and other stakeholders on the features of new models and their impact. Work with the Medical Director and Practice Transformation Consulting team to launch models with the Providers in their respective markets, at times delivering presentations on the models to Provider organizations as needed. This position will serve as department SME interacting with the Regulatory Affairs Director for Health Services Cost Review Commission (HSCRC) policies and activities to appropriately evaluate impact of value-based contracts in Maryland’s regulated environment.
• Interface and coordinate efforts with the Networks and Contract Management teams. This position is responsible for overseeing and ensuring all critical elements of the value-based contracts are tracked, properly reviewed and implemented each year. This position will be directly responsible for research related to competitiveness of contract terms and rates, alternative payment models, accountable care organizations, clinically integrated networks and other research needs of the department. This position will coordinate and ensure all performance guarantees are approved and tracked for Provider Contracting and Reimbursement. Responsible for quarterly metrics reporting related to contract reimbursement (contracting & pricing) that gets produced for the executive team. This position will be responsible for other special projects that might emerge in the course of the yearly business cycle as assigned.
• Responsible for management and oversight of relationship with any additional consultants/vendors CareFirst may contract with for value-based competitive analysis, etc.; direction and vision for policy and quality standards for all departmental work; inventory trends and impacts; tactical planning, implementation, monitoring and reporting; and ad hoc executive management reporting.
• Bachelors’ degree in Business, Healthcare, Finance or related field or equivalent experience, with strong financial background. In lieu of a bachelor’s degree, must have 4 years related experience.
• Minimum of 7 years’ experience in health care insurance industry with specific experience in contracting, negotiation and reimbursement development;
• Deep knowledge of value-based programs and contract structure
• Experience with tracking and reporting related to departmental functions.
• Effective management skills to plan, direct, and monitor department activities to ensure the achievement of corporate and divisional goals.
• Strong interpersonal skills to effectively represent the Payment Transformation team within the organization and represent CareFirst to the provider community.
• Capable of balancing contract negotiations and quality service with institutional and professional providers.
• Ability to present professionally to senior leadership internally and externally outside of CareFirst
• Project management expertise
• Excellent verbal and written communication skills
• Effective negotiation skills and service oriented. Needs to balance negotiation and service. This will require the ability to problem solve through negotiation and diplomacy.
• The ability to maintain and build relationships within the community and the company at different organizational levels.
• Self-directed with the ability to work independently and make decisions in a changing environment
• Demonstrated successful planning and organizational skills in developing and implementing strategic and tactical plans.
• 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.
• Analytical skills principles as evidenced by CPA or MBA highly desirable
• Knowledge of CareFirst’s or other payer’s provider networks and contracts
• Proficient in computer software applications
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: 4/17/2020
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