Network Contract Analyst

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the business needs, along with internal pay equity and external market-driven rates. The salary range displayed has not been adjusted for geographical location.

Benefits

• Comprehensive benefits package including Medical, Dental & Vision coverage
• Retirement Plan
• Generous time off including Paid Time Off, Holidays, and Volunteer Time Off
• Incentive Plan
• Tuition Reimbursement

About Us

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 Blue Cross, 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. 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. Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association.

Responsibilities

• Assist in developing an annual plan for the team which considers available resources and anticipated workload.
• Perform 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.
• Develop 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, including 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.
• Review the Special Pricing Factor related to ITS claims.
• Present suggestions for developing and revising workflows relating to various aspects of the team’s provider contract administration activities.
• Respond to questions and concerns raised by providers related to their contracts with the Plan, including inquiries about annual Blue Cross cost reports, reimbursement implications, changes of ownership, and analysis of payment levels.
• Assist with the resolution of problems involving reimbursement issues encountered during the preparation of contract settlements or received directly from providers.
• Participate in drafting contracts for new providers and amending contracts for existing providers, considering requirements of model contracts filed with the Pennsylvania Insurance Department and unique provider issues.
• Assist with data analysis to support Provider Contracting during provider contract negotiations, ensuring timely and accurate information is available.
• Represent the team in Plan projects that affect various other departments and involve provider and/or provider reimbursement and contracting issues.
• Research, evaluate, and analyze provider payment modifications at the State and Federal level, including mandates, demonstration programs, or program initiatives.
• Develop proactive analytical studies to assess changes in provider billing patterns, charge description masters, and other variable reimbursement provisions.
• Perform data analysis and studies pertaining to aspects of provider reimbursement with a focus on retro/prospective impacts.
• Communicate impacts to Manager Network Analytics & Contract Support, Senior Network Directing Analyst, Network Directing Analysts, or negotiation team.
• Develop analysis to routinely monitor provider billing practice changes.
• Respond to and provide documentation for claim payment audits and surveys from internal and external sources (e.g., BCBSA, FEP, Medicare, Model Audit Rule).
• Coordinate the configuration and implementation of comprehensive professional provider pricing schedules, including rate calculations for fee exceptions for professional providers for all lines of business.
• Perform audit functions on the work of others in the Provider Operations unit.
• Assist with the implementation process for maintenance of pricing schedules in accordance with network strategies.

Requirements

• 2-3 years’ experience in a healthcare environment with proven analytical expertise.
• Bachelor's Degree preferred in accounting, business administration, health planning and administration, or an Associate’s degree with sufficient work experience in healthcare or healthcare insurance pertaining to reimbursement or finance.

Skills

• Fairness, honesty, and respect for all team members.
• 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 organization and prioritization of tasks to meet deadlines and department goals.
• Ability to recognize potential problem areas and 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 clearly and concisely, incorporating industry knowledge to recommend solutions.
• Demonstrated ability to prepare detailed reports that accurately communicate issues and recommended actions.
• Demonstrated ability to understand the nature and complexities of data and relationships within databases.
• Ability to communicate with provider financial personnel on topics spanning services to reimbursement, maintaining professionalism to uphold good provider relations.
• Flexibility in work habits and patterns to respond to changes impacting the healthcare environment.
• Demonstrated ability to drive results to completion while managing multiple projects and priorities.

Knowledge

• Knowledge of Capital BlueCross provider contract provisions.
• Demonstrated knowledge and development experience with tools such as Microsoft Office Suite (Access, Excel, Word), Crystal Reports, Tableau, and SAS.
• Intermediate skill level in Access, including query development, table joins, and formulas.
• Intermediate level in Excel utilizing formulas, pivot tables, and other functions.
• Working knowledge of claim and/or Facets data elements; experience with SAS or Tableau is preferred.
• Familiarity with the operational aspects of different provider types, including 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).

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.