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.”

Responsible for standard contracting with professional providers, ancillary providers, and hospitals. Tasks include executing contracts with new providers and amending contracts for existing providers. Requires attention to regulatory requirements; collaboration with Legal Department, Network Operations, and Provider Engagement; understanding of the financial impact to all lines of business; and knowledge of network adequacy needs and network designs. Assists the Director of Provider Contracting in supporting Capital BlueCross's overall provider network strategy, including leading network adequacy review and outreach. Supports the Director on projects related to hospitals, networks, reimbursement methodologies, contract documents, mailings, and statutory and broad-sweeping amendments. Represents contracting department at internal work groups and/or on-going oversight groups to ensure adherence to Capital's contracts and advise such groups as to business processes or strategies that align with contract terms and conditions. Provides administrative support to Director.

• Responsible for contract administration tasks including but not limited to: administering standard contracts for all provider types, completing non-financial contract amendments, and executing negotiated single patient agreements.
• Responsible for review of network adequacy, identifying key prospects to close gaps in line with network strategy, facilitating and tracking outreach activities, reporting gap closure status, and achieving compliance with network adequacy standards dictated by various governing bodies.
• Projects and Strategy - Assists and executes operational tasks associated with special projects requiring mass mailings, broad sweeping amendments, and focused recruitment for a specific provider type. Participates in workgroup meetings and supports cross departmental projects to ensure adherence to Capital’s contracts/network strategies and fulfil needed contracting tasks associated with the projects. Responsible for understanding the competitive pricing levels in the local market, and assists contractors with maintaining and improving Capital BlueCross’ cost position through unit costs strategies. Drives and/or assists contracting management and staff with the development and deployment of medical cost savings strategies designed to improve plan performance both financially and in relation to member satisfaction
• Provides administrative support including but not limited to creating and maintaining internal contract tracking methodologies to ensure contracts are executed in a timely manner and are appropriately retained and disseminated. Periodic presentations to management on contract execution status and projected outcomes is required.
• Responsible for timely reviews of departmental and cross departmental policies to ensure compliance with regulatory requirements, accuracy with updated procedures and organizational structure, and communication to users for consistent adherence.

Skills:

• Ability to collaborate with cross functional areas utilizing social, influential skills to produce effective results.
• Strong written/verbal communication skills. 8. Ability to coordinate, prioritize, and organize tasks and schedules to meet and balance priorities and objectives set forth by Provider Network Engagement and the providers. 9. Ability to adapt to changing priorities in a fast-paced environment as well as work independently with minimal direct supervision.

Knowledge:

• Comprehensive understanding of claims system capabilities with regard to certain reimbursement methodologies and network system configuration.
• Broad knowledge and understanding of the Medicare Program reimbursement methodologies, and requirements for Medicare Advantage Organizations.
• Knowledge of provider contracting arrangements, including the various reimbursement methodologies and other material provisions.
• Knowledge of evolving health care practices and their applicability to benefit plan designs and contracting. Knowledge of consumer oriented plan designs.
• General knowledge of the various State and Federal licensing requirements and bodies, existing accreditation organizations such as the Joint Commission, and the various types of criteria established and being established by such organizations.

Experience:

• Minimum 3 years related work experience, preferably with a strong understanding of Blue Cross Plans.

Education and Certifications:

• Prefer at least a Bachelor Degree in business, healthcare, finance.

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 be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

Other:

• Travel: Possession of valid driver’s license, and willingness to travel periodically within the service area.

 

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 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.