Horizon Blue Cross Blue Shield of New Jersey
Dir, Network & Physician Contracting
Horizon Blue Cross Blue Shield of New Jersey, Parsippany, New Jersey, United States
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.
Responsibilities
Lead the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospitals, and ancillary facilities across the payment spectrum.
Responsible for achieving the Enterprise Unit Cost Trends which is critical in the Enterprise meeting its Annual Financial and Strategic Plan.
Lead Fee for Service (FFS) and Value Based negotiations and/or contracting arrangements across all provider types and all of Horizon's lines of business (Commercial, Braven, Medicaid and Horizon Casualty Services).
Collaborate with the payment evolution team to introduce updated payment models (whether FFS or value‑based) and partner with the provider experience team to meet provider expectations.
Ensure regulatory, accreditation and enterprise network adequacy requirements are met to provide Horizon members access to a broad network across all lines of business.
Perform periodic network analyses from cost, coverage, and growth perspectives and lead opportunities to expand or modify the network to meet enterprise goals.
Oversee budgeting and forecasting initiatives for product lines to network costs and provider contracts.
Draft hospital, professional and ancillary contract terms to conform with regulatory and enterprise requirements while advancing Horizon's strategy.
Manage negotiations and contracting with all providers for all payment arrangements, including FFS and value‑based primary and specialty programs.
Negotiate, execute, and renew contracts for all providers and all payment arrangements while maintaining contract standards and policies.
Collaborate with the payment strategy team on contracting parameters and with the provider experience team on relationships.
Recruit and contract with out‑of‑network providers.
Develop and execute 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.
Develop and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
Ensure accurate contract loading and submissions, interface with matrix partners for network implementation and maintenance across all lines of business.
Maintain contract and special arrangement reporting, provider file maintenance requests, claims stops and new hospital implementation; adjudicate technical inefficiencies related to system‑wide claims, configuration, and provider mapping discrepancies.
Manage contract inventory and ensure adherence to all regulatory requirements and internal policies, supporting claim payment accuracy and timeliness.
Identify and achieve multi‑million‑dollar medical cost savings by introducing innovative industry initiatives and programs.
Achieve the Enterprise Unit Cost Trends and maintain financial forecasts for hospital, professional, and ancillary unit costs.
Ensure compliance with all regulatory, accreditation and enterprise network adequacy requirements and maintain geo‑access standards.
Oversee the maintenance of all provider contract language and templates to ensure they can be configured into core systems.
Collaborate with Legal and Compliance Leadership to modify provider contract templates for regulatory compliance.
Understand the Enterprise Strategic and Financial Plan, Value Based Programs, credentialing and re‑credentialing processes, provider directory maintenance, and regulatory standards.
Collaborate across departments to align provider services with member and organizational needs, keeping the provider network integrated with organizational objectives.
Assist the team with the skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals.
Represent the organization at industry conferences, webinars, and other events to position Horizon well within its market.
Manage, develop, and train staff; set goals, conduct annual performance reviews, and administer staff salaries.
Education / Experience
High School Diploma/GED required.
Bachelor’s degree in business, finance, accounting, health administration or related field preferred; or equivalent experience.
Master’s degree in health or business preferred.
Minimum 10 years of experience in complex healthcare environments, including managed care, hospital finance, and network development.
Minimum 10 years of progressive experience in Healthcare Administration, Managed Care, or Provider Contracting.
Minimum 8 years of experience negotiating with health care executives, providers, and accreditation/regulatory personnel.
Minimum 8 years of experience with contract finance and reimbursement modalities including FFS, Medicare DRG, APCs, Medicaid pricing, capitation, full risk, shared savings, and incentive arrangements.
Minimum 8 years of health care cost data analysis and technical document writing.
Track record in developing and managing successful network contracting strategies, negotiating complex contracts with executives and providers.
Knowledge of quality measurement approaches for insurance, HMO, hospital, and physician practice performance.
Minimum 5 years of management and supervisory experience.
Skills and Abilities
Excellent negotiation, communication, and leadership skills; works with executive stakeholders internally and externally.
Strong negotiation skill set with ability to facilitate resolution of barriers.
Health care financial acumen including budget setting and forecasting.
Ability to create, develop, and maintain business relationships.
Proven analytical, business case, and product design skills.
Sound judgment and thorough information gathering.
Detail oriented with strong organizational skills and problem‑solving ability.
Flexibility and adaptability in multiple responsibilities and areas.
Effective presentation and communication skills to managers, clients, and customers.
Ability to deliver highly technical information to non‑technical audiences.
Positive working relationships with all internal and external stakeholders.
Willingly work with in‑house and outside counsel to complete agreements.
Attention to detail in contractual and quality monitoring aspects required by law or credentialing organizations.
Knowledge
Proficiency in personal computer use and supporting software in a Windows environment (MS Office).
Knowledge of basic intranet and internet applications.
Principles of health care contracting.
Health care and health insurance industry knowledge.
Knowledge of hospital and physician communities in New Jersey.
Knowledge of laws and regulations regulating insurance, HMO, hospital, and physician practice.
Travel
Moderate travel up to 60% required; willing to travel to healthcare facilities.
Benefits
Comprehensive health benefits (Medical/Dental/Vision)
Retirement plans
Generous PTO
Incentive plans
Wellness programs
Paid volunteer time off
Tuition reimbursement
Salary Range $152,500 - $208,110
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status, or any other protected class as required by law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.
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Responsibilities
Lead the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospitals, and ancillary facilities across the payment spectrum.
Responsible for achieving the Enterprise Unit Cost Trends which is critical in the Enterprise meeting its Annual Financial and Strategic Plan.
Lead Fee for Service (FFS) and Value Based negotiations and/or contracting arrangements across all provider types and all of Horizon's lines of business (Commercial, Braven, Medicaid and Horizon Casualty Services).
Collaborate with the payment evolution team to introduce updated payment models (whether FFS or value‑based) and partner with the provider experience team to meet provider expectations.
Ensure regulatory, accreditation and enterprise network adequacy requirements are met to provide Horizon members access to a broad network across all lines of business.
Perform periodic network analyses from cost, coverage, and growth perspectives and lead opportunities to expand or modify the network to meet enterprise goals.
Oversee budgeting and forecasting initiatives for product lines to network costs and provider contracts.
Draft hospital, professional and ancillary contract terms to conform with regulatory and enterprise requirements while advancing Horizon's strategy.
Manage negotiations and contracting with all providers for all payment arrangements, including FFS and value‑based primary and specialty programs.
Negotiate, execute, and renew contracts for all providers and all payment arrangements while maintaining contract standards and policies.
Collaborate with the payment strategy team on contracting parameters and with the provider experience team on relationships.
Recruit and contract with out‑of‑network providers.
Develop and execute 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.
Develop and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
Ensure accurate contract loading and submissions, interface with matrix partners for network implementation and maintenance across all lines of business.
Maintain contract and special arrangement reporting, provider file maintenance requests, claims stops and new hospital implementation; adjudicate technical inefficiencies related to system‑wide claims, configuration, and provider mapping discrepancies.
Manage contract inventory and ensure adherence to all regulatory requirements and internal policies, supporting claim payment accuracy and timeliness.
Identify and achieve multi‑million‑dollar medical cost savings by introducing innovative industry initiatives and programs.
Achieve the Enterprise Unit Cost Trends and maintain financial forecasts for hospital, professional, and ancillary unit costs.
Ensure compliance with all regulatory, accreditation and enterprise network adequacy requirements and maintain geo‑access standards.
Oversee the maintenance of all provider contract language and templates to ensure they can be configured into core systems.
Collaborate with Legal and Compliance Leadership to modify provider contract templates for regulatory compliance.
Understand the Enterprise Strategic and Financial Plan, Value Based Programs, credentialing and re‑credentialing processes, provider directory maintenance, and regulatory standards.
Collaborate across departments to align provider services with member and organizational needs, keeping the provider network integrated with organizational objectives.
Assist the team with the skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals.
Represent the organization at industry conferences, webinars, and other events to position Horizon well within its market.
Manage, develop, and train staff; set goals, conduct annual performance reviews, and administer staff salaries.
Education / Experience
High School Diploma/GED required.
Bachelor’s degree in business, finance, accounting, health administration or related field preferred; or equivalent experience.
Master’s degree in health or business preferred.
Minimum 10 years of experience in complex healthcare environments, including managed care, hospital finance, and network development.
Minimum 10 years of progressive experience in Healthcare Administration, Managed Care, or Provider Contracting.
Minimum 8 years of experience negotiating with health care executives, providers, and accreditation/regulatory personnel.
Minimum 8 years of experience with contract finance and reimbursement modalities including FFS, Medicare DRG, APCs, Medicaid pricing, capitation, full risk, shared savings, and incentive arrangements.
Minimum 8 years of health care cost data analysis and technical document writing.
Track record in developing and managing successful network contracting strategies, negotiating complex contracts with executives and providers.
Knowledge of quality measurement approaches for insurance, HMO, hospital, and physician practice performance.
Minimum 5 years of management and supervisory experience.
Skills and Abilities
Excellent negotiation, communication, and leadership skills; works with executive stakeholders internally and externally.
Strong negotiation skill set with ability to facilitate resolution of barriers.
Health care financial acumen including budget setting and forecasting.
Ability to create, develop, and maintain business relationships.
Proven analytical, business case, and product design skills.
Sound judgment and thorough information gathering.
Detail oriented with strong organizational skills and problem‑solving ability.
Flexibility and adaptability in multiple responsibilities and areas.
Effective presentation and communication skills to managers, clients, and customers.
Ability to deliver highly technical information to non‑technical audiences.
Positive working relationships with all internal and external stakeholders.
Willingly work with in‑house and outside counsel to complete agreements.
Attention to detail in contractual and quality monitoring aspects required by law or credentialing organizations.
Knowledge
Proficiency in personal computer use and supporting software in a Windows environment (MS Office).
Knowledge of basic intranet and internet applications.
Principles of health care contracting.
Health care and health insurance industry knowledge.
Knowledge of hospital and physician communities in New Jersey.
Knowledge of laws and regulations regulating insurance, HMO, hospital, and physician practice.
Travel
Moderate travel up to 60% required; willing to travel to healthcare facilities.
Benefits
Comprehensive health benefits (Medical/Dental/Vision)
Retirement plans
Generous PTO
Incentive plans
Wellness programs
Paid volunteer time off
Tuition reimbursement
Salary Range $152,500 - $208,110
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status, or any other protected class as required by law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.
#J-18808-Ljbffr