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CareFirst BlueCross BlueShield · 1 day ago

Provider Contracting Specialist - (Remote)

United States

Full-time

Remote

Entry, Mid Level

$63K/yr - $125K/yr

2+ years exp

CareFirst BlueCross BlueShield is a healthcare organization focused on providing quality services, and they are seeking a Provider Contracting Specialist. This role will lead negotiations for provider-specific contracts, analyze financial data, and ensure compliance with regulatory requirements while overseeing complex projects related to provider contracts.

Health CareNon ProfitService Industry

No H1B

Responsibilities

Serves as a consultant and subject matter expert (SME) in contracting and reimbursement, offering insights during contract development and negotiations with smaller provider practices based on claims and market analysis

Supports negotiations, development of strategy, market and provider intelligence, and contract execution for institutional, ancillary and professional providers, including implementation oversight. Uses claims and code data to draft and negotiate fixed-price and cost reimbursement care contracts

Evaluates reimbursement inquiries and develops cost-effective and competitive reimbursement strategies, with an emphasis on transitioning from fee-for-service to value-based care

Reviews the performance of provider partners based on utilization, trends, and quality metrics to develop rate/reimbursement solutions. Ensures that contracts clearly outline responsibility for performance costs, and that profit or fee incentives offered are tailored to the uncertainties involved in contract performance

Collects, analyzes, and interprets data from internal and external sources (e.g., cost of care, services, codes, market trends) to ensure accuracy and relevance for network partners

Reviews various healthcare reimbursement methods and projects financial impacts of provider contracts within predetermined targets, summarizing findings using charts, graphs, tables or narratives

Responsible for developing and maintaining relationships with contracted healthcare providers across various specialties

Collaborates with internal teams within Health Services to identify and address gaps in accessibility and network adequacy through recruitment and contracting. Ensures a balanced network composition that is geographically competitive, offers broad access, and meets cost and trend management objectives

Monitors and remains current on political, legal, compliance and regulatory trends

Ensures contracts comply with applicable state and federal regulations and guidelines and actively participates in workgroups or legislative committee meetings

Coordinates administrative tasks with internal departments to address questions, issues, and activities related to provider contracts

Validates final agreements and amendments to ensure accuracy and inclusion of all negotiated changes, ensuring timely and correct payments for services rendered

Qualification

Contract NegotiationHealthcare ReimbursementData AnalysisFinancial AnalysisProject ManagementRelationship BuildingMicrosoft Office 365Interpersonal SkillsProblem SolvingCommunication Skills

Required

Bachelor's Degree in Business Administration, Healthcare, Public Health, Finance or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience

2 years healthcare, business or related field

1 year experience in contracting, provider recruitment or provider relations

Understanding of multiple reimbursement methodologies used in healthcare provider contracting, including third party payment methodologies, delegated arrangements and payor networks (PPO, HMO, value-based contracting, etc.)

Effective time and project management skills to be able to plan and monitor activities to ensure achievement of organizational goals

Strong interpersonal skills to effectively interface with all levels of staff, providers, vendors, and business-related associates. Ability to lead project teams towards goal attainment and work independently or as part of a team

Strong analytical, problem-solving and critical thinking skills, with the ability to use reason to identify problems, gather data, establish facts, draw valid conclusions and develop suitable recommendations to propose and if necessary, negotiate with the external parties

Proficient with financial analysis/modeling and Microsoft Office 365 including Word, Excel, Outlook and Teams

Strong negotiation and relationship building skills, along with an understanding of contractual documents and the ability to effectively communicate terms to providers

Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging

Preferred

Master's degree in Business or Healthcare Administration

Knowledge of healthcare or health insurance payor industry (Medicare, Medicaid, Commercial, DSNP and other payor programs), including legal and regulatory requirements

Solid understanding of CPT-4, HCPCS, revenue and ICD coding, medical terminology, claims payment, contract negotiations and problem resolution