This position is responsible for leading the network operations and the contract reimbursement and pricing function. This includes supporting and participating in contract negotiations; providing data driven solutions in coordination with internal and external business. Leads meetings with senior business leaders to ensure a data- driven, consultative analytics process is incorporated into sound business decisions.
This positon is also responsible for facilitating the development, coordination, communication, and accomplishment of short and long-term business initiatives. The incumbent will act as a liaison between the department and other constituencies and will represent the department when the senior leader's attendance is not required.
Responsibilities:
Directs the development and implementation of contracting reimbursement and pricing arrangements. Participates in leading joint planning, implementation and maintenance of contracts with providers.
Provides leadership and direction for change management initiatives, project management, and program implementation on behalf of Department Leadership.
Collaborates cross divisionally and achieves actionable results through others, builds strong and sustainable relationships, and interacts effectively with all levels of the organization.
Provides SME leadership for complex projects involving multiple resources and tasks, providing individual mentoring in support of company objectives around identifying network, value-based model and deal performance.
Develops and monitors strategic plans, budgets and actions in support of the business plan relative to network management.
Navigates across multiple analytical and business units to socialize and gain buy-in for pricing, results and interpretation, including making recommendations on how to use the results to refine value-based models.
Implement financial models to be used for all types of Medicaid and Medicare providers including Hospitals, Physicians, Ancillary and Special providers.
Provides meaningful analysis of data, interpretation of results, and appropriate reporting to senior management throughout the organization. Incorporates metrics and benchmarks (both internal and external as appropriate).
Disseminates information and communicates ideas on behalf Department Leadership.
Manages highly confidential information.
Tracks progress against plans, identifies any deviations and suggests plans to remediate; provides reports and analysis as required.
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.
Knowledge:
Requires understanding of managed care business processes, data, systems, and applications for claims payment, enrollment, benefit design, product pricing, network and provider contracting, and utilization management. Health Care provider or relating Consulting activities can be substituted for Managed Care experience.
Requires proficiency with very large data sets (i.e. claims elements, membership, authorization, etc.) and software/coding (i.e. SAS).
Requires knowledge of typical business objectives and strategies in care, utilization, and network management functions.
Requires proficiency in MS Office (particularly Excel including formulas, calculations and graphs);
Requires other database software experience with SAS experience a major plus.
Requires technical skills with database concepts, data analysis development, data warehousing, and decision support tools.
Expertise in all forms of Government reimbursement mechanisms.
Knowledgeable of reimbursement methodologies employed for different provider types.
Able to compare and contrast various reimbursement models and work with leadership to ensure most favorable pricing models are developed.
Able to take a key role in negotiations to explain financial models.
Skills and Abilities:
Ability to plan, organize, coordinate, and direct multiple projects and activities with varied deadlines.
Change management experience in developing and implementing significant culture change within complex organizations.
Ability to problem-solve and operate effectively within a dynamic, results-driven environment.
Requires proven quantitative and financial analysis skills.
Requires the ability to express thoughts clearly and concisely, both verbally and in writing.
Requires demonstrated ability to work in a team environment and get results in a consultative manner.
Requires attention to detail and granular levels of analysis.
Requires a demonstrated aptitude for analytical thinking and the ability to report findings in an accurate manner.
Requires outstanding organizational skills including the ability to plan organize and prioritize work assignments.
Requires computer with Microsoft Office products including XL, and other database software. SAS experience a plus.
Requires technical skills with database concepts, data analysis development, data warehousing, and decision support tools; along with awareness of system development processes.
Solid understanding of operations, reporting and forecasting.
Understands and demonstrates a strong support of all ethical issues, including confidentiality.
Strong interpersonal, consensus building and conflict resolution skills.
Ability to influence individuals at all levels of the organization.
Education:
Requires a Bachelor's degree from an accredited college or university, preferably in Analytics, Information Systems, Business, Economics, Finance, Mathematics, Computer Science, Public Health, Nursing, or a related field.
Masters degree in Business Administration, Health Administration or similar degree preferred.
Experience:
Requires a minimum of 8 years of experience in Analytics, Informatics, Medical Economics or other relevant work experience. Must have demonstrated expertise in provider negotiations.
Requires 5 years supervisory staff management and administrative experience.
Project Management Professional (PMP) certification desired.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.
