Blue Cross Blue Shield Of Florida Jacksonville , FL 32277
Consultant Provider Reimbursement
Provide expertise in the design, development and maintenance of Provider Network Management alternative payment reimbursement systems, processes and capabilities in support of critical business initiatives with focus on financial value outcomes and risk mitigation.
Coordinate implementation of enhancements for delivered functionality by/while defining business requirements for projects that are complex in scope and needed to meet assigned project objectives.
Develop insights and recommendations that influence management decision-making through gathering and analyzing of financial and provider data.
Lead and provide expertise to functional and technical project teams and may participate in cross-functional initiatives.
Integrate work from multiple systems, (business and IT) to generate payment related reference artifacts which successfully facilitate financial processes and outcomes of value.
Support the design and development of complex tools, applications, processes, or functionality which supports compliance using controls and alerts to achieve outcome.
Act as subject matter expert and owner in financial design, support, and maintenance of complex reimbursement arrangements.
Monitor and assess financial output and identify areas of concern and lead process improvement.
Prepare business areas for implementation (Operational Readiness) by developing/ delivering training and coordinating creation of SOP's with SME's.
Bachelor's degree or equivalent work experience
6 years related work experience or equivalent combination of transferrable experience and education
Experience in Healthcare industry, with a focus on reimbursement capabilities and provider payment programs and policy
Proficiency with business strategy monitoring and ensuring compliance with regulatory and BCA payment policies end-to-end business processes
Must possess a sound knowledge of the insurance/managed care industry practices and regulatory standards with focus on financial implications and outcomes
Proven ability to manage large-scale, complex change efforts and projects, including the design, development, and implementation of innovative business capabilities intended to achieve strategic direction
Demonstrated ability to achieve business results in an environment of ambiguity, challenge and constantly changing business needs
Must have ability to influence, manage, collaborate and build relationships with individuals across the organization and achieve results through those who are not direct reports
Must be able to communicate highly detailed and technical information in a concise and understandable way to all levels of the organization
Must be results-oriented, a consistent top performer in meeting or exceeding goals, and proficient in decision-making and implementing viable solutions based upon sound judgment, analysis and knowledge/experience
Advanced level proficiency of Microsoft Office (Word, Excel, PowerPoint and Outlook)
Understanding of PeopleSoft Financial System
Working knowledge of Network Management/ Network Operations' applications/data systems/ contracting/ enrollment and process workflow mapping
Advanced level of understanding related to various payment programs across the spectrum of provider reimbursement (i.e., fee for service, capitation, DRG, per diem, etc.)
Experience with data impacting reimbursement (member, group, provider, product, payee)
Advanced level of understanding related to various provider types and their aligned payment programs across the contracting and reimbursement spectrum of Florida Blue.
Exhibits proficiency in the ability to negotiate, resolve and problem solve cross-departmental issues in a respectful, professional manner.
Ensures solutions are in compliance with company standards.
Working knowledge of Network Management/Network Operations' applications/data systems/ contracting/ enrollment and process workflow mapping