Resp & Qualifications
PURPOSE: This position reports to the Manager, Government Programs and Projects and is responsible for the planning and managing of day to day network operations, activities and compliance matters regarding the Medicare Advantage network and additional future Medicare networks. This position is responsible for preparation of CareFirst’s entry into Medicare Advantage markets, network expansion and ongoing development, maintenance and oversight. This position is responsible for contracting strategy development and ensuring competitive network access for CareFirst members that meets all jurisdictional requirements.
This senior-level expert is responsible for strategy, negotiation, and oversight of complex provider contract negotiations for Medicare Advantage including negotiations with large health systems that will serve as anchor providers for the Medicare Advantage network. These anchor provider relationships represent approximately $1.5B in commercial spend will be a key factor in the success of Medicare Advantage. This position in coordination with the Provider Contracting and Recruitment department and Legal, and establishing and maintaining external relationships with key provider partners in collaboration with, and support of the Practice and Payment Transformation team in their Total Cost of Care (TCOC) negotiations and implementation
This position will be responsible for coordination with Sales and Marketing for new product development. Responsibilities include oversight and coordination with all functional areas, development of detailed work plans with clearly defined deliverables, dates and accountable personnel, implementation and post implementation follow-up and monitoring in coordination with corporate Medicare committees.
This position will develop processes and procedures related to coordination with Provider Contracting and Reimbursement departments for the contracting and reimbursement of select providers. This position reports to the Manager, Government Programs and Projects, but matrixed reporting relationships will occur, as needed. This position is responsible as a Subject Matter Expert on network matters, reimbursement and contracting strategies for Medicare Advantage to other Departments within CareFirst that may be the “business owner” of Medicare programs.
Under the general supervision of the Manager, Government Programs and Projects the incumbent’s accountabilities include, but are not limited to the following:
Duties and Responsibilities
Manage, plan and organize departmental functions associated with the development and maintenance of the Medicare Advantage and other future Medicare networks. This involves, but not limited to, the following accountabilities:
• Develop, in coordination with senior leadership, the scope and responsibilities of new department.
• Establish and maintain strong collaboration with Medicare committees, Sales, Marketing, Actuarial, Medicare, Legal, Practice and Payment Transformation, Health Services, and other departments as needed for development of new networks.
• Responsible for competitive network access (balancing cost, quality, and access) for current and future Medicare networks, including but not limited to development of contracting strategies.
• Work with appropriate teams for consistent monitoring and ongoing maintenance and ensure continued network access in accordance with Medicare, NCQA and other access requirements.
• Develop processes, procedures, and policies in coordination with Embedded Compliance team. Ensure staff is trained and adheres to policies and procedures. Prepare and submit monthly performance metrics as needed.
• Remains alert and informed to industry trends and held accountable and credible in the eyes of internal and external customers to be an expert in the area.
Leads strategy, negotiation and oversight of complex health system and provider negotiations in coordination with Provider Contracting and Recruitment. Develops and maintains processes for the coordination, collaboration, and hand-off to Provider Contracting for the contracting of selected providers based on quality, cost, provider scorecard and other factors as appropriate for the development of each new network.
Chairs and/or represents Networks Management on external and internal committees (and departments) to support Medicare program and networks, corporate initiatives, legislative requirements and system initiatives.
• 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.
• 3-5 years Medicare experience
• Minimum of 7 years’ experience in healthcare insurance industry with specific experience in contracting, negotiation and reimbursement development.
• Effective team leading skills to plan, direct, and monitor department activities to ensure the achievement of corporate and divisional goals.
• Extensive knowledge of the healthcare industry, legal/regulatory issues and operations knowledge, including thorough knowledge of provider reimbursement methodologies and claims processing guidelines.
• Strong interpersonal skills to effectively represent Networks Management within the organization and represent CareFirst interest to the provider community.
• Effective human relation skills to direct, lead, and motivate team members towards goal attainment.
• Strong analytical skills are needed to evaluate financial arrangements and negotiate cost effective terms.
• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as the ability to understand and interpret complex information from others. Proficient in speaking in both individual and group settings, particularly with providers and internal staff.
• Ability to multi-task, shifting back and forth effectively among multiple activities.
• 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: 8/30/2020
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