Resp & Qualifications
Oversees the Maryland Medicaid and DSNP provider engagement model to drive membership growth through positive provider relationships with the plan and coordinates with the overall CareFirst organization on delivery of that engagement model. Manages the relationship with the Maryland Department of Health in regards to Provider Engagement and other relevant business functions. Provider engagement incorporates activity from a quality, population health and financial outcome standpoint. This role will work closely with the Health Services matrixed organization supporting the plan to coordinate the Provider, Network, Quality, and Clinical activities with the operational and external activities of the plan. The role will also collaborate with quality to measure and track the effectiveness of the clinical operations and their interactions with the other plan functions, developing and implementing plans to improve overall plan effectiveness and administrative costs.
POSITION DUTIES AND RESPONSIBILITIES
• Manage all relationships between the plan and Health services within CareFirst
• Directs the needs of the MD Medicaid and D-SNP plans other functions with those managed by Health Services
• Drive Network Strategy in collaboration with Networks for MD Medicaid and D-SNP plans
• Directs the coordination for all quality activities between health services and the plan
• Leads the interface with external parties and drives the planning and execution, leveraging internal stakeholders. Track and validate all contracted expectations for clinical, quality, and network activities per the contracts with the state and CMS
• Work with Health Services leadership to address gaps or operational concerns to ensure plan compliance with the contracts
• Develop productive relationships with business leaders across the organization to influence how applications can enable new sources of value
• Lead the successful delivery of desired business outcomes in partnership with business colleagues.
• Partner with stakeholders to define a prioritized set of business outcomes and application work to accomplish those outcomes within the limitations of the budget.
• Partner with stakeholders to accomplish portfolio work in a way that improves the business and technical fitness of the line of business portfolio and minimizes its ongoing support costs.
Required: An undergraduate or postgraduate degree in healthcare, finance, business management or a related field. 8 years of previous experience in clinical, quality, network with government funded healthcare programs (Medicare, Medicaid, ACA). 3 years of direct management experience.
• Proven understanding of core clinical operations principles of a healthplan
• Strong communication skills with a proven ability to understand key concepts and communicate effectively with other functional partners, business stakeholders and senior management.
• Proven ability to communicate operational concepts to enhance understanding and drive decisions that lead to positive outcomes.
• Proven ability to collaborate, build relationships and influence individuals at all levels in a matrix-management environment (as well as external vendors and service providers) to ensure that segregation and overlapping roles are identified and coordinated.
• Strong organizational skills, the ability to perform under pressure and management of multiple priorities with competing demands for resources.
• Strong analytical, data-processing and problem-solving skills.
• Proficiency in process formulation and improvement.
• Experience building and sustaining business relationships.
Department: MD Medicaid -HEALTH SERVICES
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: 7/2/21
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
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