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, drives strategic opportunities specific to an assigned group of provider partners that may include hospitals/health systems, physician practices, and/or ancillary providers, and creates a strong relationship role that produces mutually beneficial contracts and programs. This individual executes strategies to benefit Capital and its Members while maintaining partnerships throughout contract negotiations. Takes accountability and ownership for efficient and timely conclusion of negotiations and execution of contracts Assists in the ongoing development, modification, and implementation of Capital BlueCross' provider network strategy as well as leading the implementation of innovative product designs for contracted providers. Responsible for the negotiating reimbursement approaches aligning with strategic goals, contract structures, product design/network configurations and intelligence gathering. Responsible for the negotiation of reimbursement approaches aligning with strategic goals, contract structures, product design/network configurations and market intelligence. Responsible for the negotiation of contract terms that meet business needs and can be systematically administered, meet regulatory limitations and requirements, consider the financial impact to all lines of business, and are closed in a timely manner. Responsible for presenting and gaining the appropriate level of internal approvals for proposed contract terms. Under the direction of Corporate and Network leadership this position will manage the transformation from the network's fee-for-service driven model to a model that includes value-based programs and products that align with Quadruple Aim objectives (improved member satisfaction, provider satisfaction, quality, and cost), to include capitated risk arrangements, special needs plans, and MA-VBID models. Engaged in the performance of provider incentive programs for STARS and risk adjustment to ensure all providers are performing at 4 STARS or higher. The individual will work collaboratively with a team of internal partners across all business segments. Supports the Director of Provider Contracting and/or Senior Director in the management of complex projects related to hospitals, and extending to all provider types where the complexity is elevated, network development activities, reimbursement methodologies, contract documents, and statutory and broad-sweeping amendment plans. Leads teams to implement various contracting or network-oriented strategies, including ongoing oversight, as necessary. This position will represent the provider contracting unit at a variety of internal work groups and/or on-going oversight committees. As a representative the individual will ensure adherence to both Capital's existing contracts and alignment to strategic contract and reimbursement plans and advise such committees as to business processes or strategies that align with contract terms and conditions, and those that do not.

• Serves as principal lead on a defined number of hospitals and/or professional and/or ancillary providers for negotiation, strategy, and market and provider intelligence. Responsibility may relate to significant provider spend ($200+ million). Must develop a level of trust and credibility with key provider partner contacts, and foster a business relationship beneficial to Capital BlueCross for purposes of maintaining and improving the existing Capital BlueCross relationships. Provides market intelligence to Capital’s leadership and makes recommendations for strategies that may appropriately leverage key partnerships.
• Engages with provider partners on financial incentive programs that offer additional revenue opportunities and is the primary spokesperson to assigned providers for all medical value initiatives.
• 20% - Assists in the establishment of contracting and contract related criteria and guidelines to optimize financial performance and minimize Plan risk. Plays a key contact providing support for information and education around programs. Lead in acquisition and merger strategies and contract requirement fulfillments for all assigned providers.
• Oversight and responsibility for the financial, data and statistical analysis needs of the contracting function with respect to specific negotiations. Responsible for communicating analytical needs to appropriate internal staff, including the competitive pricing development of systematic methodologies. Uses unit medical cost strategies to support responsible stewardship of Member and customer healthcare dollars.
• Responsible for understanding provider partners’ service needs, incorporating contract solutions to support both providers and Capital BlueCross in reaching shared goals. Responsible for investigating and generating any business improvement that may be gained through a contracting modification, effort or initiative.
• Directs and manages special projects affecting networks and health systems, 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 committees, project teams and/or task forces.

Skills:

• Demonstrated ability to negotiate contract language provisions typically found in Provider Agreements for Commercial and Medicare Advantage markets.
• Proven and strong negotiation and written and verbal communication skills, which are necessary to communicate to varied audiences ranging from internal claims managers to hospital CEOs, on subjects ranging from technical to subjective in nature.
• Proven ability to identify/formulate projects of major importance and scope and follow through to conclusion of projects successfully without direct supervision.
• Ability to apply situational negotiation techniques to achieve desired outcomes.
• Ability to interpret and manipulate data to demonstrate outcomes of proposed negotiation tactics.
• Advanced ability to develop collaborative relationships through written/verbal communication and in a virtual environment.
• Ability to coordinate, prioritize, and organize tasks and schedules to meet and balance priorities and objectives set forth by Director/Sr. Director and the providers. Ability to adapt to changing priorities in a fast-paced environment as well as work independently with minimal 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.
• Demonstrated ability to coordinate, plan and engage a team in the design of systematic applications of contract provisions in a complex claims processing system preferred.
• Demonstrated financial acumen and analytical skills to translate data into action.

Knowledge:

• Broad knowledge and understanding of the Medicare Program reimbursement methodologies, and Medicare Advantage Programs.
• Knowledge of industry provider contracting arrangements and methodologies including reimbursement methods; quality plans and initiatives; provider tiering arrangements.
• Knowledge of evolving health care practices and their applicability benefit plan designs and contracting. Knowledge of consumer-oriented plan designs.
• Knowledge of the various State and Federal licensing and oversight bodies, existing accreditation organizations (NCQA, AHRQ, JCAH, CARF, etc.) and the various criteria established and being established by such organizations.
• Preferred strong understanding of Blue Cross Plans.
• Knowledge of evolving health care practices and their applicability benefit plan designs and contracting. Knowledge of consumer-oriented plan designs.
• Demonstrated attributes for independently leading a provider negotiation and performing as an active team member on inner departmental negotiation strategy development for Hospital, affiliated Health System providers, and/or Accountable Care Organization engagements.
• Active team contributor as network contracting lead for cross functional teams engaged in high profile projects involving Corporate Initiative contracting efforts to strategically realign contractual provisions with the fast-paced evolution of market standards.
• Demonstrated achievement as a cross-functional team lead on process design, improvement, or project planning activities.
• Ability to quickly gain knowledge of new business processes and issues applying effective change plans.

Experience:

• 8 years related work experience with at least 5 of those years including direct payer/provider negotiation experience with complex, financially significant relationships between payers, health systems, large independent practices, and/or clinically integrated networks.
• 2 years operational experience with value-based programs (ACO, PCMH, and Bundled Payments) preferred.

Education and Certifications:

• Bachelor’s Degree in business, finance, healthcare management, clinical/medical science, or a related field.
• Master’s degree preferred.
• Possession of valid driver’s license, and willingness to travel frequently within the service area.

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.

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 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.