Resp & Qualifications
PURPOSE:
This role will lead, guide, strategize and manage negotiations for provider-specific institutional, ancillary, and professional contracts. Key responsibilities include negotiating contract terms in accordance with regulatory requirements, analyzing financial data to evaluate implications across various business lines, while ensuring compliance with company policies and procedures, and coordinating with the Payment Transformation team to transition fee-for-service arrangements to value-based care. This role will also oversee complex projects related to provider contracts, reimbursement methods, documentation and amendments, and participate in internal workgroups and committees, ensuring compliance and advising on business strategies. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.
ESSENTIAL FUNCTIONS:
Contract Development and Negotiation
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Serves as a consultant and subject matter expert (SME) in contracting and reimbursement, offering insights during contract development and negotiations with smaller provider practices based on claims and market analysis. Supports negotiations, development of strategy, market and provider intelligence, and contract execution for institutional, ancillary and professional providers, including implementation oversight. Uses claims and code data to draft and negotiate fixed-price and cost reimbursement care contracts. Evaluates reimbursement inquiries and develops cost-effective and competitive reimbursement strategies, with an emphasis on transitioning from fee-for-service to value-based care. Reviews the performance of provider partners based on utilization, trends, and quality metrics to develop rate/reimbursement solutions. Ensures that contracts clearly outline responsibility for performance costs, and that profit or fee incentives offered are tailored to the uncertainties involved in contract performance.
Research and Data Analysis
- Collects, analyzes, and interprets data from internal and external sources (e.g., cost of care, services, codes, market trends) to ensure accuracy and relevance for network partners.
Reviews various healthcare reimbursement methods and projects financial impacts of provider contracts within predetermined targets, summarizing findings using charts, graphs, tables or narratives.
Recruitment and Relationship
- Responsible for developing and maintaining relationships with contracted healthcare providers across various specialties. Collaborates with internal teams within Health Services to identify and address gaps in accessibility and network adequacy through recruitment and contracting. Ensures a balanced network composition that is geographically competitive, offers broad access, and meets cost and trend management objectives.
Regulatory and Healthcare Landscape
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Monitors and remains current on political, legal, compliance and regulatory trends. Ensures contracts comply with applicable state and federal regulations and guidelines, and actively participates in workgroups or legislative committee meetings.
Administration
- Coordinates administrative tasks with internal departments to address questions, issues, and activities related to provider contracts. Validates final agreements and amendments to ensure accuracy and inclusion of all negotiated changes, ensuring timely and correct payments for services rendered.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Business Administration, Healthcare, Public Health, Finance or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 2 years healthcare, business or related field and 1 year experience in contracting, provider recruitment or provider relations.
Preferred Qualifications:
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Masters degree in Business or Healthcare Administration.
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Knowledge of healthcare or health insurance payor industry (Medicare, Medicaid, Commercial, DSNP and other payor programs), including legal and regulatory requirements.
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Solid understanding of CPT-4, HCPCS, revenue and ICD coding, medical terminology, claims payment, contract negotiations and problem resolution.
Knowledge, Skills and Abilities (KSAs)
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Understanding of multiple reimbursement methodologies used in healthcare provider contracting, including third party payment methodologies, delegated arrangements and payor networks (PPO, HMO, value-based contracting, etc.).
- Effective time and project management skills to be able to plan and monitor activities to ensure achievement of organizational goals.
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Strong interpersonal skills to effectively interface with all levels of staff, providers, vendors, and business-related associates. Ability to lead project teams towards goal attainment and work independently or as part of a team.
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Strong analytical, problem-solving and critical thinking skills, with the ability to use reason to identify problems, gather data, establish facts, draw valid conclusions and develop suitable recommendations to propose and if necessary, negotiate with the external parties.
- Proficient with financial analysis/modeling and Microsoft Office 365 including Word, Excel, Outlook and Teams.
- Strong negotiation and relationship building skills, along with an understanding of contractual documents and the ability to effectively communicate terms to providers.
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.
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Salary Range: $63,792 - $126,698
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
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.
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.
PHYSICAL DEMANDS:
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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