Network Contract Analyst

About the role

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.

Responsibilities

• Aid in the development of an annual plan for the team which considers available resources and anticipated workload.
• Perform 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.
• Present suggestions for use in developing and revising the workflows relating to various aspects of the team’s provider contract administration activities.
• Respond to questions and concerns raised by providers which are directly or indirectly related to their contracts with the Plan.
• Assist with the resolution of problems involving reimbursement issues encountered either during the preparation of contract settlements or received directly from providers.
• Participate in drafting contracts for new providers and in amending contracts for existing providers.
• Assist with the data analysis to support Provider Contracting during provider contract negotiations.
• Represent the team in Plan projects that affect various other departments and which 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.
• Communicate to Manager Network Analytics & Contract Support, Senior Network Directing Analyst, Network Directing Analysts or negotiation team in relation to impacts.
• 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, etc.).
• 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.

Qualifications

• 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 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.
• 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.
• Demonstrated ability to drive results to completion while managing multiple projects and priorities.
• Knowledge of Capital BlueCross provider contract provisions.
• Knowledge of general accounting practices and auditing procedures/techniques.
• Familiarity with Medicare and Medicaid reimbursement methodologies (facility and professional providers).

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 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.
• 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.
• Demonstrated ability to drive results to completion while managing multiple projects and priorities.

Benefits

Capital Blue Cross offers a comprehensive benefits package 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.

Pay

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 BlueCross at the time of posting and may be modified in the future.

Schedule

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.

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 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. Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.