Network Contracting Account Specialist

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Lead and facilitate negotiations with hospital, physician, and ancillary network providers.

• Collaborate with Medical Economics, Actuary, Payment Model Evolution, and Provider Experience teams to prepare contract rate proposals.

• Assist in fee-for-service and value-based payment contracting initiatives throughout Horizon's lines of business.

• Oversee the execution and maintenance of the network contracting strategy and policies.

• Ensure accurate implementation of contracts and special arrangements across various systems.

• Handle provider file maintenance requests, claims stops, and onboarding of new hospitals.

• Evaluate claims, configuration, provider mapping, and identify technical inefficiencies across systems.

• Investigate operational issues, pinpoint root causes, and analyze fallout reports.

• Coordinate the loading of hospital, ancillary, and professional rates, pricing configurations, DRG updates, and contract storage.

• Address contract reporting, provider file maintenance, claims stop, and hospital implementation challenges with matrix partners.

• Assess contracts to identify potential medical cost savings and implement industry initiatives.

• Maintain provider contract language and templates, ensuring compatibility with core systems.

• Partner with Legal and Compliance teams regarding contract templates and regulatory requirements.

• Develop and institute provider contracting policies and procedures.

• Contribute to the value-based contracting strategy and enterprise affordability objectives.

• Collaborate across departments to synchronize provider services with the needs of members and the organization.

• Prepare materials for industry conferences, webinars, and various events.

⛳️ Requirements

• High School Diploma/GED is required.

• Bachelor's degree in business, finance, accounting, or health administration is preferred, or relevant experience may suffice in lieu of a degree.

• A Master's degree in health or business is preferred.

• A minimum of 5 years of business experience in hospital finance and/or managed care network development is required.

• At least 5 years of demonstrated experience in two or more areas with comprehensive knowledge of contract finance and reimbursement methodologies, including FFS, Medicare DRG and APCs, Medicaid pricing, capitation, full risk, shared savings, and incentive arrangements.

• Minimum of 5 years of provider experience in Commercial, Medicare, Medicaid, and Value-Based Programs is required.

• At least 5 years of experience in healthcare cost data analysis and technical document writing.

• Proficient in personal computers and supporting software in a Windows-based environment, including MS Office products (Word, Excel, PowerPoint).

• Familiarity with intranet and internet applications.

• Knowledge of the principles of healthcare contracting.

• Understanding of the healthcare or health insurance industry.

• Familiarity with hospital and physician communities in New Jersey.

• Knowledge of insurance, HMO, hospital, and physician practice laws and regulations.

• Understanding of quality measurement approaches used in insurance, HMO, hospital, and physician practice.

• Ability to cultivate, develop, and sustain business relationships.

• Strong analytical, business case, and product design skills.

• Capacity to exercise sound judgment, ask insightful questions, and gather thorough and relevant information.

• Detail-oriented with excellent organizational, problem-solving, and task-following skills.

• Ability to manage multiple responsibilities across various organizational areas.

• Capability to present information and respond to inquiries from groups of managers, clients, and customers.

• Effective verbal and written communication skills, with the ability to work collaboratively within a team.

• Horizon BCBSNJ employees must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement plans.

• Generous paid time off (PTO).

• Incentive plans.

• Wellness programs.

• Paid volunteer time off.

• Tuition reimbursement.

• Moderate travel is required.