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.”

The Network Contract Analyst performs contract administration activities encompassing among other tasks the preparation of contract settlements to ensure that claims are ultimately paid in accordance with the provisions of the contracts and that the Plan payment levels are reasonable and accurate based on the nature and scope of services rendered. The Network Contract Analyst performs research, analytic and reporting work in support of the Provider Contracting and Value Based Programs ACA agreements, provider reimbursement strategies and new contracting initiatives. The Network Contract Analyst works with team manager and other analysts from within the same unit, other Provider Operations areas or the negotiating team to develop and administer contracts between Capital BlueCross and various providers of health care services, including hospitals, non-hospital providers, ancillary providers and professional providers.

• Assist in developing an annual plan for the team which considers available resources and anticipated workload.
•  Responsible for the analytical functions necessary to effectively and efficiently administer provider contracts.
• Prepare provider contract settlements ensuring that the work performed supports the conclusions reached and that the settlements issued are accurate and reflect the payment provisions of the respective contracts.
• Develops the anticipated settlements to providers where payments made systematically don’t adequately address all reimbursement provisions of the provider contracts to ensure that adequate reserve requirements are provided for by the Plan
• Manage the Cost Rate Adjustment (CRA) process. Activities involve the accumulation of information from Network Analytics & Contract Support staff, reconciliation of data to the previous period and Accounting records, investigation and resolution of any differences and preparation of analysis, as well as the review of the Special Pricing Factor related to ITS claims.
• Presents suggestions for use in developing and revising the workflows relating to various aspects of the team’s provider contract administration activities
• Responds to questions and concerns raised by providers which are directly or indirectly related to their contracts with the Plan. Sources of the inquiries include, but are not limited to, the annual Blue Cross cost reports, reimbursement implications of transactions or claims, the implications from changes of ownership or changing locations where services are rendered and the analysis of payment levels in relation to services rendered or not rendered.
• Assists with the resolution of problems involving reimbursement issues encountered either during the preparation of contract settlements, or received directly from providers. Issues are addressed based on an understanding of the facts and analysis in the context of the payment provisions applicable to the provider’s contract and/or the Plan’s reimbursement policy and encompass the research of technical and operational matters. The conclusions reached in all cases must be thoroughly documented and communicated to the respective provider or requestor through the appropriate channel, i.e., Provider Relations, Legal, etc.
• Participates in drafting contracts for new providers and in amending contracts for existing providers. Activities involving both new contracts and contract amendments consider the requirements of model contracts filed with the Pennsylvania Insurance Department as well as the identification of unique provider issues that need to be addressed in the contracts.
• Assist with the data analysis to support Provider Contracting during provider contract negotiations. Ensure that timely and accurate information is available for the Provider Contracting staff considering relevant issues concerning data and the provider have been addressed.
• Represent the team in Plan projects that affect various other departments and which involve provider and/or provider reimbursement and contracting issues. The position interacts with other Plan areas to resolve problems identified during the performance of our contract administration duties.
• Research, evaluate and analyze provider payment modifications at the State and Federal level, including mandates, demonstration programs or program initiatives. Keep appropriate Plan personnel informed of the changing payment methodologies which may impact our existing contracts with member providers or contracting strategies.
• Develop proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions.
• Data analysis and studies pertaining to aspects of provider reimbursement with a focus on retro/prospective impacts.
• Communication to Manager Network Analytics & Contract Support, Senior Network Directing Analyst, Network Directing Analysts or negotiation team in relation to impacts.
• Development of analysis to routinely monitor provider billing practice changes.
• Responds to and provides documentation for claim payment audits and surveys from internal and external sources (e.g., BCBSA, FEP, Medicare, Model Audit Rule, etc.).
• Coordinates the configuration and implementation of comprehensive professional provider pricing schedules including rate calculations for fee exceptions for professional providers for all lines of business. Performs audit functions on the work of others in the Provider Operations unit.
• Assists with the implementation process for maintenance of pricing schedules in accordance with network strategies.

Skills:

• Fairness, honesty and respect for all team members. Demonstrate strong interpersonal effectiveness among all levels within the unit/department.
• Strong oral and written communication skills.
• Ability to perform in a team environment.
• Ability to work independently with minimal supervision including the organization and prioritization of tasks to meet prescribed deadlines and department goals.
• Ability to recognize potential problem areas (i.e. those that materially affect reimbursement) and quickly differentiate between those which can be resolved directly versus those requiring assistance.
• Ability to perform analytic functions necessary to effectively and efficiently administer provider contracts.
• Ability to perform data analysis and studies pertaining to aspects of provider reimbursement.
• Ability to review data and summarize it in a clear and concise manner incorporating industry knowledge to recommend solutions.
• Demonstrated ability to prepare detailed reports that accurately communicate the issue and recommended action in a clear and concise manner.
• Demonstrated ability to understand the nature and complexities of data and the relationships of data tables and elements within databases.
• Ability to communicate with provider financial personnel on topics spanning from range of services to those relating to reimbursement. This requires a high degree of professionalism in order to maintain good provider relations.
• Flexibility in work habits and patterns in order to respond to the constant and numerous changes impacting the health care environment.
• Demonstrated ability to drive results to completion while managing multiple projects and priorities.

Knowledge:

• Knowledge of Capital BlueCross provider contract provisions.
• Demonstrated knowledge of and development experience with various tools such as Microsoft Office Suite products (Access, Excel, Word, etc.), Crystal Reports, Tableau, and SAS. Ability to perform at an intermediate skill level in Access including query development, table joins and formulas. Ability to perform at an intermediate level in Excel utilizing formulas, pivot tables and other functions/formulas. A working knowledge of claim and/or Facets data elements and experience with SAS or Tableau is preferred.
• Familiarity with the operational aspects of different provider types with an understanding of their claims submission requirements and provider reimbursement methodologies.
• Familiarity with Plan operations.
• Knowledge of general accounting practices and auditing procedures/techniques.
• Familiarity with Medicare and Medicaid reimbursement methodologies (facility and professional providers).

Experience:

• 2-3 years’ experience in a health care environment with proven analytical expertise is desired.

 

Education and Certifications:

• Prefer a Bachelor's Degree in one of the following; accounting, business administration, health planning and administration or an Associate’s degree with sufficient level of work experience in health care or health care insurance pertaining to reimbursement or finance.

Work Environment:

• Working environment includes typical office conditions.

Physical Demands:

• 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.

 

 

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.