Dir, Network & Physician Contracting

Horizon Healthcare Services•Hopewell, NJ

About The Position

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. Lead the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospital, and ancillary facilities across the payment spectrum. Responsible for achieving the Enterprise Unit Cost Trends which is critical in the Enterprise meeting its Annual Financial and Strategic Plan. Lead Fee for Service (FFS) and Value Based negotiations and/or contracting arrangements across all provider types and all of Horizon’s lines of business (Commercial, Braven, Medicaid and Horizon Casualty Services) which requires developing a sound business strategy for the financial and legal terms required for contracting initiatives. Collaborating with the payment evolution team to introduce the appropriate updated payment models (whether FFS or value based) and provider experience team to meet provider expectations. Responsible for achieving all the regulatory, accreditation and enterprise network adequacy requirements to ensure Horizon’s members have access to a broad network across all its lines of business. Perform periodic analyses of the provider network from a cost, coverage and growth perspective and provide leadership in evaluating opportunities to expand or modify the network to meet the enterprise goals.

Requirements

High School Diploma/GED required.
Bachelor degree in business, finance, accounting, health administration or any other related field preferred or relevant experience in lieu of degree.
Master’s degree in health or business preferred.
Requires a minimum of 10 years of experience in complex environments within healthcare, healthcare consulting or managed care as well as experience in hospital or healthcare finance and/or managed care network development.
Requires a minimum of 10 years of progressive experience in Healthcare Administration, Managed Care and or Provider Contracting.
Requires a minimum of 8 years demonstrated experience to facilitate negotiations with health care executives, provider’s and accreditation and regulatory personnel.
Requires a minimum of 8 years demonstrated in-depth knowledge and experience in contract finance and reimbursement. methodologies including FFS, Medicare DRG and APC’s, Medicaid pricing, capitation, full risk, shared savings and incentive arrangements.
Requires a minimum of 8 years demonstrated experience in health care cost data analysis and technical document writing.
This director will have a demonstrated track record of developing and managing successful network contracting strategies, with experience negotiating complex contracts with healthcare executives and providers.
Requires knowledge of quality measurement approaches applied in measuring insurance, HMO, hospital, and physician practice performance.
Requires a minimum of 5 years management and supervisory experience.
Excellent negotiation, communication and leadership skills are needed as this director will work with a range of executive stakeholders both internally and externally.
Strong negotiator with the ability to facilitate the resolution of barriers utilizing business contacts negotiations and skills.
Demonstrated health care financial acumen including budget setting and forecasting.
Demonstrates ability to create, develop, and maintain business relationships.
Proven analytical, business case and product design skills a must.
Proven ability to exercise sound judgment.
Proven ability to ask probing questions and obtain thorough and relevant information.
Must be detail oriented with strong organizational skills.
Proven ability to follow detailed instructions is essential, along with proven problem-solving skills.
Demonstrates flexibility and adapts to multiple responsibilities encompassing multiple areas within the organization.
Must demonstrate the ability to effectively present information and respond to questions from groups of managers, clients, customers.
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
Demonstrated ability to deliver highly technical information to less technical individuals.
Able to interact and create positive working relationships with all levels of internal and external constituents and staff.
Willingness to work closely with in-house counsel as well as outside counsel to complete agreements.
Requires an attention to details, contractual and quality monitoring details often prescribed through law or credentialing organizations.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint); Should be knowledgeable in the use of intranet and internet applications.
Requires knowledge of Principals of Health Care contracting.
Requires knowledge of health care industry or health insurance industry.
Requires knowledge of the hospital and physician communities in the state of New Jersey.
Requires knowledge of laws and regulations regulating insurance, HMO hospital and physician practice.
Moderate travel up to 60% required.
Must be willing to travel to various healthcare facilities.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Nice To Haves

Master’s degree in health or business preferred.
Bachelor degree in business, finance, accounting, health administration or any other related field preferred or relevant experience in lieu of degree.

Responsibilities

Oversee budgeting and forecasting initiatives for product lines to network costs and provider contracts.
Draft hospital, professional and ancillary contract terms to ensure they conform with all regulatory, accreditation and enterprise requirements while advancing Horizon’s strategic and business objectives.
Manage negotiations and contracting with all providers for all payment arrangements, including FFS and value-based primary and specialty programs.
Negotiate, execute, and renew contracts for all providers and all payment arrangements. Maintain contract standards and policies.
Collaborate with the payment strategy team on contracting parameters and provider experience team on relationships.
Recruit and contract with out-of-network providers.
Development and execution of the network contracting strategy, including methods to adopt value-based contracting for providers operating under fee-for-service models, minimize special arrangements, and align to enterprise affordability objectives.
Develop and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
Accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance all lines of business.
Coordination across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, DRG updates and contract storage.
Ensures accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider file maintenance requests, claims stops and new hospital implementation.
Adjudication of technical inefficiencies as it relates to system wide claims, configuration, and provider mapping discrepancies.
Conducts research, identify root cause analysis and work fall out reports causing operational deficiencies.
Ensures effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures.
Understands the impact of provider contract provisions on claims payment accuracy and timeliness and presents solutions to minimize unnecessary deviation and supports auto-adjudication.
Identifying and achieving multi-million-dollar medical cost savings by introducing innovative industry initiatives and programs.
Achieve the Enterprise Unit Cost Trends.
Accountable for all hospital, professional and ancillary unit cost financial forecasts.
Achieving all regulatory, accreditation and enterprise network adequacy requirements.
Meet all geo-access standards.
Oversees the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the core systems.
Collaborate with Legal and Compliance Leadership as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and enterprise requirements.
Understand the Enterprise Strategic and Financial Plan
Understand Value Based Programs including the financial, quality, and operational aspects.
Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
Collaborate across departments to ensure that provider services are aligned with the needs of members and the organization.
Keep the provider network integrated with the organization’s objectives.
Assist the team with skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals.
Evaluate and negotiate contracts in compliance with Horizon reimbursement standards, and other key controls.
Represent the organization at industry conferences, webinars, and other events. Ensures that Horizon is well-positioned to identify and capitalize on emerging trends and opportunities in Horizon’s market.
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.