Provider Contract Manager

About the role

The role leads strategic provider partnerships—such as with hospitals, physician groups, and ancillary providers—to negotiate mutually beneficial contracts and support Capital Blue Cross's goals.

Responsibilities

• Serves as principal lead on a defined number of providers for negotiation, strategy, and market intelligence.
• Must develop a level of trust and credibility with key provider partner representatives and foster a business relationship beneficial to Capital Blue Cross.
• Provides market intelligence to Capital’s leadership and makes recommendations for strategies that appropriately leverage key partnerships.
• Engages with provider partners on financial incentive programs offering additional revenue opportunities and is the primary spokesperson to assigned providers for all medical value initiatives.
• Assists in the establishment of contract-related criteria and contracting guidelines to optimize financial performance and minimize Plan risk.
• Serves as a key contact providing support for information and education around programs.
• Lead in acquisition and merger strategies and contract requirement fulfillments for all assigned providers.
• Has oversight and responsibility for the financial, data and statistical analytic needs of the contracting function specific to negotiations.
• Responsible for communicating analytical needs to appropriate internal staff, including the competitive pricing development of systematic methodologies.
• Uses unit medical cost strategies to support responsible stewardship of Member and customer healthcare dollars.
• Responsible for understanding provider partners’ service needs and incorporating contract solutions to support providers and Capital Blue Cross in reaching shared goals.
• Responsible for investigating and generating business improvement concepts that may be gained through contracting modification, effort or initiative.
• Directs and manages any necessary special projects affecting networks and health systems.
• Ensures all appropriate internal departments and constituencies are involved and provides clear communication.
• Serves as the ongoing contracting area liaison and advisor for any variety of process development and oversight committees, project teams and/or task forces.

Qualifications

• 8 years related work experience with at least 5 of those years including direct payer/provider negotiation experience with complex, financially significant relationships between payers, health systems, large independent practices, and/or clinically integrated networks.
• 2 years operational experience with value-based programs (ACO, PCMH, and Bundled Payments) preferred.

Skills

• Demonstrated ability to negotiate contract language provisions typically found in Provider Agreements for Commercial and Medicare Advantage markets.
• Penned and strong negotiation, written, and verbal skills necessary to communicate with varied audiences on subjects ranging from technical to subjective in nature.
• Penned and strong ability to identify/formulate projects of major importance and scope and follow through conclusion successfully without direct supervision.
• Enhanced ability to develop collaborative relationships through written/verbal communication, both in person and in a virtual environment across the enterprise and with providers.
• Ability to adapt to changing priorities in a fast-paced environment while working independently with minimal direct supervision.
• Demonstrated ability to apply Plan policy and mission to ongoing activities generated by non-traditional occurrences within the provider community.
• Demonstrated ability to coordinate, plan and engage a team in the design of systematic applications of contract provisions in a complex claims processing system preferred.
• Demonstrated financial acumen and analytical skills to translate data into action.
• Broad knowledge and understanding of the Medicare Program reimbursement methodologies, and Medicare Advantage Programs.
• Knowledge of industry provider contracting arrangements and methodologies including reimbursement methods; quality plans and initiatives; provider tiering arrangements.
• Knowledge of evolving health care practices and their applicability benefit plan designs and contracting.
• Knowledge of consumer-oriented plan designs.
• Knowledge of the various State and Federal licensing and oversight bodies, existing accreditation organizations (NCQA, AHRQ, JCAH, CARF, etc.) and the various criteria established and being established by such organizations.
• Possession of valid driver’s license, and willingness to travel frequently within the service area.

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

Schedule

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.

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.