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Strategic Provider Relationship Manager
4 months ago
Position Description:
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”
This position is responsible for developing and executing best-in-class provider engagement with assigned multimillion-dollar, strategic provider organizations/health systems. This individual is responsible for interfacing directly with physicians, team members, and management at all levels of the health system organization as well as within Capital Blue Cross. The individual will be the point person for all questions and issues from any of the provider types/service lines within the health systems including hospital, physician, practices, vendors, and ancillary providers. They will serve as liaison between the provider and internal areas at Capital, establishing themselves as a trusted advisor by overseeing elevated issues to resolution, educational programs, onsite/virtual meeting agenda, and special initiatives. This individual will work hand-in-hand with the Network Contractor to maintain a full view of the health system relationship, provide insight for negotiations, and co-lead any actions needed to support the strategic objectives. Focus is on building and preserving strong provider relationships and the impact to value-based contracts, quality care for our members, reduced cost of care, compliance with contracts and regulatory requirements, member experience, and administrative efficiencies.
Responsibilities and Qualifications:
- Lead execution of the full spectrum of provider engagement activities for assigned provider organizations/health systems from the more transactional/operational aspects to the more strategic partnership opportunities including initial onboarding, ongoing account management, and activities that a involve a strategic partnership (i.e. build a product and/or network to support strategic membership growth tied to corporate objectives) or integration opportunities (i.e. data sharing, automation, etc.).
- Serve as the point of contact and driver for escalated provider matters and contractual issues across various lines of business, with limited supervision. Resolve conflict in a productive and direct manner by leveraging relationship with provider, relationships with supporting departments within Capital, and negotiation skills. Identify, develop, and conduct proactive communications/training with health systems to minimize provider and member abrasion, operational issues, and confusion on topics spanning end to end operations.
- Optimize provider engagement and performance (operational, quality, and cost) of assigned providers through close collaboration with Sales, Clinical, Claims, Provider/Member Services, and Analytics teams. Develop, monitor, influence, and report key performance metrics to support strategic goals. Partner with Contractor to understand and support the contract and its intended outcomes for Capital including sharing critical information cross functionally within Capital, facilitating resolution efforts activities with multiple cross functional areas, and consulting on operational aspects of contract execution. Work directly with assigned market network leaders to identify providers for value-based contracting, support network in identification of relevant metrics and benchmarks for contracting, assists with proposal and counter-proposal preparations and assists with periodic reconciliations and required data sharing processes.
- Leverage negotiation and project management skills to drive provider participation in strategic initiatives that will benefit Capital’s operational, financial, and/or quality performance including data sharing opportunities, quality/STARs initiatives, cost of care initiatives, MLR, risk adjustment, record retrieval/EMR access, Commercial HEDIS, and other initiatives as needed. Conduct provider performance assessments, collect market intel, and obtain provider strategies to maintain the Provider Profile and provide consultation/recommendations to Healthcare Delivery Leadership for strategy development, contractual negotiations, and product/network development.
**Job Requirements**
- Demonstrated ability to build and maintain valuable business relationships in a fast-paced environment.
- In-depth understanding of the provider community (market knowledge) and global knowledge of care delivery models, reimbursement methodologies, and insurance industry.
- Ability to understand and analyze financial modeling and value based reporting to comprehend and discuss quality and cost drivers.
- Knowledge of required compliance with CMS laws and regulations, policies and guidelines for our Medicare Advantage plans, HIPAA privacy and security regulations, and accreditation requirement.
- Adept at using Microsoft Office Suite of products (such as Word, Access, Excel, Power Point, Outlook, etc.)
**S
