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.”

This position will lead all aspects of Capital’s network contracting activities related to traditional FFS and value-based reimbursement methodologies for the network portfolio; including facility, ancillary, and professional providers. Responsible for direct oversight, management and training of the contracting staff reporting to this position. Responsible for the negotiation of contract terms, unit cost management, and strategic network-inspired product designs - such as, tiered or narrow networks etc. Leads the transformation of Capital’s existing network from a primarily fee-for-service driven model to a model to value based programs that align with the Triple Aim objectives (satisfaction, quality, and cost). The individual will manage and oversee complex projects related to provider networks, reimbursement methodologies, and the contractual/statutory/regulatory requirements necessary to ensure compliance with such items as network adequacy etc. Provide leadership in evaluating opportunities to expand or change the network to meet company goals. Must be able to manage budgeting and forecasting initiatives for product lines to network costs and provider contracts. Oversee analysis of claim trend data and/or market information to drive conclusions to support contract negotiations.

• Demonstrate and provide leadership capabilities to develop and deploy complex contracting activities through multiple reimbursement methodologies and to meet overall company objectives. Maintains a positive relationship with all external stakeholders to ensure key contracting objectives can be met. Negotiates all key terms of contractual arrangements within key timeframes required to maintain contractual relationship.
• Lead, manage, and oversee contracting staff assigned to the position with the intent to develop skillsets and knowledge to assist in delivering accurate, timely and judicious contract terms.
• Demonstrate and provide leadership capabilities in the transition and growth of value-based contracting strategies to support corporate goals and objectives. Lead the development and implementation of “best practice” alternate payment models. Closely monitor CMS’ developments and regulations on healthcare reform to evaluate and incorporate align strategies related to MACRA. Incorporates strategies to align performance-based incentive models between facility and professional contracts.
• Lead, manages, and oversees complex special projects effecting network and providers such as, reimbursement policies, mass contracting efforts, and vendor strategies that support multiple cross-functional goals and objectives.
• Develop medical costs savings strategies designed to improve plan performance - financially, clinically, and member/provider satisfactions. Serves as a liaison for multiple internal work-groups tied to care costs actions. Assists department head in the development of strategy development, as well as, market and provider intelligence gathering.
• Oversight of financial, quality, and statistical analysis of contracting functions with respect to specific negotiations. Responsible for communicating analytical and modeling requirements to internal departments. Develops forecasting and budget anticipations related to contractual agreements and monitors actual to budget variances throughout the year.

Skills:

• Must be able to lead and motivate individuals and organization within an ever-changing environment. Demonstrated character, competence, and courage to have the social influence in which they can enlist the aid and support of others in the accomplishment of departmental and corporate objectives. Builds and maintains valuable business relationships in fast-paced environment.
• Strong analytic and conceptual skills to develop new analytic and financial models. Strong decision making, problem solving, and customer presentation skills (verbal and written). Ability to analyze complex problems and issues, determine impact, and develop business solutions or recommendations for changes.

Knowledge:

• Knowledge of current and emerging reimbursement and alternate payment models, to include governmental reimbursement methodologies. Understands contractual language and necessary provisions to support corporate goals. Knowledgeable of various State and Federal licensing requirements and bodies; and existing accreditation organizations (Joint Commission, CARF etc.). Ability to quickly gain knowledge of new business processes and issues.

Experience:

• A minimum of seven years of successful management experience in a health care related business, with a minimum of 5 years negotiating provider agreements. 2-3 years’ contractual and/or operational experience with value based programs (ACO, PCMH, and bundled Payments) preferred

Education and Certifications:

• Minimum requirements include a Bachelor’s Degree in a health related field. Master degree highly preferred.

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.

Travel Requirements:

• Amount (20% of time) local service area (21 county)
• Must possess a valid PA driver’s license to travel to and from i.e., providers and employer groups/plan sponsors locations.

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.