This position is responsible for leading the analyzation, evaluation, development, and implementation of new and existing reimbursement policies. This role plays a critical part in ensuring these reimbursement policies align with business goals and regulatory requirements through cross-functional collaboration and a formal vetting process. In addition, this position leads and supports the organization, collaboration and facilitation of projects as well as process improvements to achieve and align with organizational goals.

Essential Duties and Responsibilities:

15% - Responsible for leading analyzation, evaluation, development and implementation of new and existing reimbursement policies.  This includes, but is not limited to, collaborating with Analytics and Reporting to run and analyze reports to view potential impacts to provider and Capital, as well as analyzing regulatory requirements and their impact on reimbursement policies.  

25% - Responsible for the development, implementation and ongoing oversight of a Reimbursement Policy Committee which consists of a cross-functional team tasked with reviewing and evaluating new and existing provider reimbursement policies.  This includes developing the committee’s strategic direction and procedures, coordinating participants from key departments, and ensuring policy alignment with regulatory standards and strategic goals.  

10% - Responsible with resolving reimbursement policy issues that arise either during contract settlements, or are received directly from the providers. This includes analyzing each issue by applying a strong understanding of relevant facts and reimbursement policies, conducting thorough research on technical and operational aspects, and ensuring that conclusions reached are thoroughly documented and communicated to the respective provider and internally through the appropriate channel (i.e., Provider Relations, Legal, etc.).

25% - Resonsible with oversight of all Network-related projects to maintain focus on timely, on-budget deliveries. Drive projects forward by leading and modeling behaviors, focusing on collaboration, accuracy, and raising issues and risks. Encourage the following of corporate project life cycle and masterful meeting guidelines and hold others accountable to those guidelines.  Consistently maintain focus on project budget and resources throughout the project life and ensure budget reconciliation is completed monthly. Utilize the enterprise resourcing report to ensure that resources are appropriately captured, and actuals are being tracked in attempt to drive better resource management capabilities. Manage the relationships with vendors to ensure that projects move forward according to schedule. Oversight of work identified within the teams to develop and monitor Key Performance Indicators and Cost-Benefit Analysis to foster savings and alignment of project deliverables to align with strategic goals. Oversight of all communication plans to make sure all stakeholders are included. Monitoring and oversee all BCBSA deliverables within Network. Oversight of the Acquisition/Mergers within the network team to ensure timely implementation of changes and to make sure all teams are working seamlessly. Oversight of the monitoring of all audit activity to ensure we are meeting accuracy and timeliness within the regulatory requirements.

25 - Responsible with oversight of the identification and continuous improvement of network policies and procedures, ensuring alignment with organizational goals through the effective use of reporting tools, data analysis methodologies, and performance metrics. Lead the design, development, and delivery of comprehensive and timely reports, dashboards, scorecards, process flows, and value stream maps to support strategic decision-making. Support the creation of baseline metrics and detailed planning related to data collection, pilot programs, quality control processes, and training initiatives.

Job Requirements:

Skills: 

• Proven leadership skills related to coaching, leading, motivating and innovating for process improvements. This includes performance appraisals as well as internally developed training programs and presentations on reimbursement policy related topics.
• Experience working with various informational or data structures include but not limited to CMS RVU files, Carrier Specific Public Use Files, Medicare Intermediaries, MediSpan, RedBook, etc., and other industry-standard data sources.
• Ability to collaborate with Capital personnel throughout the organization and establish working relationships.
• Strong interpersonal and communication skills (with proven ability to deliver reports and presentations); ability to influence colleagues to build relationships; guide and inspire team members to deliver project work on time on budget, in accordance with internal guidelines and governance.
• Ability to lead discussions with vague details or little direction with the expectation to identify ideal states and conduct gap analysis.
• Self-motivated, quick and assertive.
• Strong written and verbal communication skills.
• Extremely detailed oriented and organized.
• Ability to multi-task, and work under pressure in an ambiguous environment. Remain comfortable with change and complexity in dynamic environments.
• Ability to prioritize tasks and shift readily between the “big picture” and small-but-critical details, knowing when to concentrate on each.
• Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions in a timely responsive nature.
• BCBSA Network regulatory requirements knowledge

Knowledge:

• Comprehensive understanding of Medicare and Medicaid reimbursement methodologies and regulations, and Capital Blue Cross provider contract provisions for all provider types.
• Knowledge or experience with various tools such as Crystal Reports, Business Objects, Quality Center, Microsoft Office Suite products (Access, Excel, Word, etc.), SAS, other 3rd or 4th generation software, and knowledge of online change methodologies such as RMS or Data Warehouse philosophies.
• Familiarity with regulatory changes impacting provider reimbursement and operations.
• Familiarity with current corporate structures for health care entities.
• Familiarity with the interrelationships of Capital operations (i.e. claims processing, rating, billing, account administration, sales, etc.)
• Familiarity with operational aspects of various provider types.
• Familiarity with Project management.
• Proficiencies in MS Office applications, MS Project, Visio, Adobe, Crystal Reports, SAS, etc.
• Stays abreast of current project management, insurance industry trends, and technology through professional associations, trade journals, networking, and associated training and seminars

Experience:

• 5 years proven experience in market access or (provider network), reimbursement, or a related field within the healthcare industry.
•  Minimum 1 year staff, team lead or project lead experience.
• Experience working on cross-functional teams required.
• Experience leading significant initiatives requiring change management leadership required.

• Education, Certification and Licenses:

• Prefer a Bachelor's Degree in one of the following: accounting, business administration, finance, or health planning and administration.

• Work Environment:

• Working environment includes typical office conditions.

• 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.

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.