Network Contracting Acct Spec
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.
About the Role
This role will facilitate and lead negotiations with Horizons network of provider partners of over 32,000 professionals, 1,500 ancillary providers and 76 hospitals in our New Jersey, Pennsylvania and New York markets representing billions in spend. Negotiations will include but not limited to Hospitals, Physicians and Ancillary providers, including value based programs for all of Horizons medical lines of business including Commercial, Medicare, Medicaid, DSNP, MLTSS and Casualty services.
The role will collaborate with the Medical Economics, Payment Model Evolution Team and Provider Experience teams in preparation for contract rate proposals that adhere to Horizon’s unit price trend budget, standard payment methodologies, standard contract language, ensure compliance with all regulatory, accreditation and enterprise requirements while advancing Horizon’s strategic and business objectives
The role will work directly with the Manager on fee-for-service and value-based payment contracting initiatives for all Horizon lines of business, collaborating with the Payment Model Evolution Team when appropriate to introduce updated payment models.
The role will facilitate the execution of network contracting strategy and maintenance of contracting policies. What You'll Do
Responsibilities:
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Facilitate and lead network provider negotiations for Horizons medical lines of business, including Commercial, Medicare, Medicaid, DSNP, MLTSS and Casualty services.
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Accountable for accurate implementation of contracts, including collaborating with other departments to assure contract and special arrangements are loaded correctly. Initiate and manage provider file maintenance requests, claims stops and new hospital implementation.
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Review technical inefficiencies as it relates to system wide claims, configuration, and provider mapping discrepancies. Collaborates with other internal business partners to conduct research, identify root cause analysis and work fall out reports causing operational deficiencies.
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Collaborate with Medical Economics and Actuary to prepare rate proposals for all lines of business.
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Accountable for timely contract submission and loading. Interface with matrix partners for network implementation and maintenance of 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.
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Serves as the go-to with matrix partners to assure contract and special arrangement reporting, provider file maintenance requests, claims stops, and new hospital implementations are resolved.
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Analyze contracts to identify and implement medical cost savings by introducing innovative industry initiatives and programs.
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Accountable for the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the core systems.
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Adhere to Horizon standard contract language and payment methodologies.
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Collaborate with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and Enterprise requirements.
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Contribute to the development and execution of the network contracting strategy, including methods to adopt value-ba