Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

Leads, directs, sets primary strategy and manages certain Capital Blue Cross ancillary and professional contract negotiations. Assists in the ongoing development and modification of Capital Blue Cross's ancillary and professional network strategy, including reimbursement, contract structures, product design/network configurations and intelligence gathering. Responsible for the negotiation of contract terms that may be systematically administered, meet regulatory limitations and requirements, consider the financial impact to all lines of business, and ensure compliance to existing company-wide policy and procedures is maintained. Responsible for presenting and gaining the appropriate level of internal approvals for proposed contract terms, including oversight of any financial analysis and contract implementation. Responsible for determining need for any and all causes such as access to care, mandatory government provisions, and Group requests for Single Patient Agreements, working with cross functional units including Clinical, Special Investigations, Appeals, and Customer Service. Engages in negotiations with ancillary and professional provider types, to result in timely delivery of essential care, protecting members with cost effective contractual provider agreements. Oversees, coordinates and manages complex projects related to ancillary and professional providers, networks, reimbursement methodologies, contract documents, and statutory and broad-sweeping amendments. This position will represent the provider contracting department at a variety of internal work groups and/or on-going oversight groups. As a representative the individual will ensure adherence to Capital's contracts, and advise such groups as to business processes or strategies that align with contract terms and conditions, and those that do not.

• Serves as principal lead on ancillary and professional providers for negotiation, strategy, market and provider intelligence, and contract execution including implementation oversight. Must develop a level of trust and credibility with key providers, and foster a business relationship beneficial to Capital Blue Cross for purposes of maintaining and improving the existing Capital Blue Cross relationships.
• Is responsible for developing provider payment rate proposals for presentation to management, and possibly including the Senior Vice President Business Development. Additionally, this position may be required to perform a full and comprehensive termination analysis, presenting to plan CEO for strategy determination.
• Responsible for implementation of Single Patient Agreements with professional and assigned ancillary provider types. Strong communication channels with multiple units to ensure all relevant information is gathered to make effective decisions on need. Presentation to cross functional groups demonstrating the effectiveness of the process and outcomes of negotiation strategy.
• Serves as an industry and local topic matter expert on assigned provider specialties, applying strong business acumen to interactions with internal and external constituencies of Capital Blue Cross.
• Reviews and assesses new programs and services for potential coverage and resulting contracting needs for the Plan. Assists in the proposal of benefit plan modifications which may improve contract performance. Designs reimbursement approaches to advantage Capital Blue Cross with respect to benefit plan designs.
• Responsible for a comprehensive understanding of claims system capabilities with regard to both ancillary and professional reimbursement methodologies and network system configuration. In addition, is responsible for reporting and summarizing system enhancements to improve administration of contract terms with a positive ROI for Capital Blue Cross.
• Capable of interpretation and manipulation of financial and statistical analysis as provided by outside and internal resources with respect to specific negotiations and/or across provider specialties.
• Responsible for understanding ancillary and professional provider service needs, incorporating contract solutions to support both providers and Capital Blue Cross. Responsible for investigating and generating any business improvement that may be gained through a contracting modification, effort or initiative.
• Responsible for understanding the competitive pricing levels in the local market, and maintaining and improving Capital Blue Cross’s cost position through unit costs strategies.
• Responsible for periodic presentations to superiors and Senior Management on contract negotiation status and projected outcomes. Responsible for reporting projected outcomes to actuary when such outcomes impact projected ancillary or professional provider specialty unit cost trends. Responsible for negotiating contracts within projection model budgets.
• Establishes medical cost savings strategies designed to improve plan performance both financially and in relation to member satisfaction.
• Directs, leads and manages complex, special projects effecting network and ancillary/professional providers, as such projects may be necessary. Must ensure that all internal departments and constituencies are involved as appropriate, and communicated to as appropriate.
• Serves as the ongoing contracting area liaison and advisor for any variety of process development and oversight groups, project teams and/or task forces. Participate in cross functional workgroups on topics such as: Medical Cost of Care analysis; new benefit designs; tiered provider networks; etc.
• Provide ancillary/professional provider and market intelligence feedback to the appropriate areas within the company. Informs department management of current or potential provider issues and recommends plans of action for resolution when appropriate.

Skills:

• Proven and strong negotiation and written and verbal communication skills, which are necessary to communicate to varied audiences ranging from internal Plan personnel to external Provider representatives, on subjects ranging from technical to subjective in nature.
• Contract interpretation and basic contract provision/amendment crafting skills required for effective negotiations and issue resolutions.
• Proven ability to identify/formulate projects of major importance and scope and follow through to conclusion successfully without direct supervision.
• Ability to apply Plan policy and mission to ongoing activities generated by non-traditional occurrences within the provider community. Ability to build and strengthen relationships with providers to help differentiate Capital Blue Cross from competitors.

Experience:

• Requires five to seven-plus years related work experience, preferably with a strong understanding of Blue Cross Plans. A minimum of three years should be direct contracting related experience.

Education and Certifications:

• Prefer at least a Bachelor Degree in business, finance, or a related field.
• Possession of valid driver’s license and access to a vehicle for travel on company business.

Work Environment:

• Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions. Work requires infrequent travel to and from provider sites.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.

Location:

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays.

 

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.    
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.