Strategic Provider Relationship Manager

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.)

Skills:

• Excellent leadership skills, especially ability to influence others who are not in a direct reporting line including ability to think strategically, develop vision, and execute effectively and efficiently for both near term and long-term results.

• Proven ability to innovate and manage complex processes across multiple functional areas

• Experience working in a highly matrixed organization, with proven ability to develop internal enterprise relations, and external strategic relationships in a fast-paced environment.

• Strong decision making, problem solving, and customer presentation skills (verbal and written).

• Ability to coordinate, prioritize, and organize tasks and schedules to meet and balance priorities and objectives set forth by Network leadership and the providers.

• Negotiation skills

• Project Management skills

• Strategic Thinking

• Process/quality improvement mindset.

• Must have aptitude for a highly visible position demanding integrity, uncompromising professionalism, and conflict management.

• Ability to analyze complex problems and issues, determine impact, and develop business solutions or recommendations for changes.

• Strong written and verbal communication skills. Ability to prepare written materials and oral presentations for internal/external audiences. Includes ability to lead meetings and to develop teamwork.

• Familiarity with the Plan operations and the interrelationships of Plan operations (e.g., claims processing, rating, billing, etc.).

• Ability to adapt to changing priorities in a fast-paced environment as well as work independently with minimal direct supervision. Self-motivated and independent with the personal pride to want to deliver excellent results.

• A clear understanding of and commitment to the member impact of the team's work.

• Must have the flexibility and perception to quickly adapt to different communication styles and approaches, with the confidence to respectfully challenge differing viewpoints.

• Discretion and professionalism in all internal and external communications. Team oriented attitude with the ability to work and interact with all levels inside and outside CBC.

• Demonstrated PC literacy with ability to perform electronic research, respond to electronic requests, and effectively navigate documents and spreadsheets.

• Exceptional attention to detail, follow up, and organization.

• Possess an extraordinary ability to handle and resolve conflict in a productive, professional, and direct manner.

Experience:

• 7-10 years' experience in health insurance or related field demonstrating increasing levels of responsibility.

• Desire experience in Medicare and Commercial insurance with experience in presenting concepts to varying audiences and project management or other relevant experience with high accountability for managing multiple tasks with defined deadlines.

Education, Certification, and Licenses:

• Bachelor's degree preferred in business, clinical, or healthcare industry discipline.

• Minimum 5 years' experience in provider relations, healthcare or insurance industry in lieu of degree.

Location:

This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays.

Work Environment:

Work involves 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. Working environment includes typical office conditions.

Travel Requirements: Amount (40% of time). Current valid Pennsylvania driver license, reliable source of transportation, and willingness to travel within service area to engage with provider network.

Physical Demands: 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 occasionally lift and/or move up to 5 pounds.

Key Interfaces: Required to interface with all areas of the company and externally engages with provider network to achieve goals.

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 diverse and 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.