Mgr, Network & Physician Contracting

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.  About the Role Lead/support the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospital, and ancillary facilities across the payment spectrum. Work with the Director on the fee-for-service (FFS) and value-based payment contracting initiatives, collaborating with payment evolution team to introduce the appropriate updated payment models (whether FFS or value based) and provider experience team to meet provider expectations. Lead/support complex negotiations and/or contracting arrangements which require developing a sound business strategy for the financial and legal terms required for contracting initiatives. Responsible to work with Medical Economics and Actuary Department to draft provider rate proposals that adhere to Horizon’s unit cost trends and negotiate such proposals with hospital executives, physicians and ancillary providers directly. Manage all the regulatory, accreditation and enterprise network adequacy requirements to ensure Horizon’s 3.7 million members have access to a broad network across all its lines of business. The manager will perform quarterly analyses of the provider network from a cost, coverage and growth perspective. Provide leadership in evaluating opportunities to expand or modify the network to meet the Enterprise goals. Manages budgeting and forecasting initiatives for product lines to network costs and provider contracts. Contributes to drafting hospital, professional and ancillary contract terms to ensure they conform with all regulatory, accreditation and enterprise requirements while advancing Horizon’s strategic and business objectives This manager should have a demonstrated track record of creating and developing and managing successful network contracting strategies, with experience negotiating contracts with healthcare providers. This manager will lead a team of specialists, and independent contributors. Excellent communication and leadership skills are needed as this manager will work with a range of stakeholders both internally and externally. This position will manage negotiations and contracting with all providers for all payment arrangements, including value-based primary and specialty programs. This team will also negotiate, execute, renew contracts for all providers and all payment arrangements. They will maintain contract standards and policies. They must collaborate with payment strategy team on contracting parameters and provider experience team on relationships. Finally, they must recruit and contract out-of-network providers. What You'll Do Manage the development and execution of the network contracting strategy, including methods to adopt value-based contracting for providers operating under fee-for-service models, minimize special arrangements, and align to enterprise affordability objectives. Manage and negotiate contracts in compliance with Horizon reimbursement standards, and other key controls. Assist and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements. Ensures accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider file maintenance requests, claims stops and new hospital implementation. Adjudication of technical inefficiencies as it relates to system wide claims, configuration, and provider mapping discrepancies. Conducts research, identify root cause analysis and work fall out reports causing operational deficiencies. Manages the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the core systems. Collaborates with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and enterprise requirements. Understands the Enterprise Strategic and Financial Plan. Understands Value Based Programs including the financial, quality and operational aspects. Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance all lines of business. Coordination across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, DRG updates and contract storage. Manages the effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures. Understands the impact of provider contract provisions on claims payment accuracy and timeliness and presents solutions to minimize unnecessary deviation and supports auto-adjudication. Implements multi-million dollar medical cost savings by introducing innovative industry initiatives and programs. Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards. Collaborate across departments to ensure that provider services are aligned with the needs of members and the organization. Assist with keeping the provider network integrated with the organization’s objectives. Provide management level leadership and support all of the contracting staff. Assist the team w