Manager, Network Operations Improvement and Policy

Capital Blue Cross • Harrisburg, PA

2d

About The Position

This position is responsible for leading the analyzation, evaluation, development, and implementation of new and existing reimbursement policies. This role plays a critical part in ensuring these reimbursement policies align with business goals and regulatory requirements through cross-functional collaboration and a formal vetting process. In addition, this position leads and supports the organization, collaboration and facilitation of projects as well as process improvements to achieve and align with organizational goals.

Requirements

• Proven leadership skills related to coaching, leading, motivating and innovating for process improvements. This includes performance appraisals as well as internally developed training programs and presentations on reimbursement policy related topics.
• Experience working with various informational or data structures include but not limited to CMS RVU files, Carrier Specific Public Use Files, Medicare Intermediaries, MediSpan, RedBook, etc., and other industry-standard data sources.
• Ability to collaborate with Capital personnel throughout the organization and establish working relationships.
• Strong interpersonal and communication skills (with proven ability to deliver reports and presentations); ability to influence colleagues to build relationships; guide and inspire team members to deliver project work on time on budget, in accordance with internal guidelines and governance.
• Ability to lead discussions with vague details or little direction with the expectation to identify ideal states and conduct gap analysis.
• Self-motivated, quick and assertive.
• Strong written and verbal communication skills.
• Extremely detailed oriented and organized.
• Ability to multi-task, and work under pressure in an ambiguous environment. Remain comfortable with change and complexity in dynamic environments.
• Ability to prioritize tasks and shift readily between the “big picture” and small-but-critical details, knowing when to concentrate on each.
• Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions in a timely responsive nature.
• BCBSA Network regulatory requirements knowledge
• Comprehensive understanding of Medicare and Medicaid reimbursement methodologies and regulations, and Capital Blue Cross provider contract provisions for all provider types.
• Knowledge or experience with various tools such as Crystal Reports, Business Objects, Quality Center, Microsoft Office Suite products (Access, Excel, Word, etc.), SAS, other 3rd or 4th generation software, and knowledge of online change methodologies such as RMS or Data Warehouse philosophies.
• Familiarity with regulatory changes impacting provider reimbursement and operations.
• Familiarity with current corporate structures for health care entities.
• Familiarity with the interrelationships of Capital operations (i.e. claims processing, rating, billing, account administration, sales, etc.)
• Familiarity with operational aspects of various provider types.
• Familiarity with Project management.
• Proficiencies in MS Office applications, MS Project, Visio, Adobe, Crystal Reports, SAS, etc.
• Stays abreast of current project management, insurance industry trends, and technology through professional associations, trade journals, networking, and associated training and seminars
• 5 years proven experience in market access or (provider network), reimbursement, or a related field within the healthcare industry.
• Minimum 1 year staff, team lead or project lead experience.
• Experience working on cross-functional teams required.
• Experience leading significant initiatives requiring change management leadership required.

Nice To Haves

• Prefer a Bachelor's Degree in one of the following: accounting, business administration, finance, or health planning and administration.

Responsibilities

• Responsible for leading analyzation, evaluation, development and implementation of new and existing reimbursement policies.
• Responsible for the development, implementation and ongoing oversight of a Reimbursement Policy Committee which consists of a cross-functional team tasked with reviewing and evaluating new and existing provider reimbursement policies.
• Responsible with resolving reimbursement policy issues that arise either during contract settlements, or are received directly from the providers.
• Resonsible with oversight of all Network-related projects to maintain focus on timely, on-budget deliveries.
• Responsible with oversight of the identification and continuous improvement of network policies and procedures, ensuring alignment with organizational goals through the effective use of reporting tools, data analysis methodologies, and performance metrics.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 501-1,000 employees