Dir, Network & Physician Contracting

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. 

Lead the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospital, 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) which requires developing a sound business strategy for the financial and legal terms required for contracting initiatives. Collaborating with the payment evolution team to introduce the appropriate updated payment models (whether FFS or value based) and provider experience team to meet provider expectations.

Responsible for achieving all the regulatory, accreditation and enterprise network adequacy requirements to ensure Horizon’s members have access to a broad network across all its lines of business. Perform periodic analyses of the provider network from a cost, coverage and growth perspective and provide leadership in evaluating opportunities to expand or modify the network to meet the enterprise goals.

Responsibilities:

• Oversee budgeting and forecasting initiatives for product lines to network costs and provider contracts. 

• Draft hospital, professional and ancillary contract terms to ensure they conform with all regulatory, accreditation and enterprise requirements while advancing Horizon’s strategic and business objectives. 

• 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.  Maintain contract standards and policies.

• Collaborate with the payment strategy team on contracting parameters and provider experience team on relationships. 

• Recruit and contract with out-of-network providers.

• Development and execution of 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.

• Accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance all lines of business. Coordination across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, DRG updates and contract storage.

• Ensures accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider file maintenance requests, claims stops and new hospital implementation. Adjudication of technical inefficiencies as it relates to system wide claims, configuration, and provider mapping discrepancies. Conducts research, identify root cause analysis and work fall out reports causing operational deficiencies.

• Ensures effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures. Understands the impact of provider contract provisions on claims payment accuracy and timeliness and presents solutions to minimize unnecessary deviation and supports auto-adjudication.

• Identifying and achieving multi-million-dollar medical cost savings by introducing innovative industry initiatives and programs.

• Achieve the Enterprise Unit Cost Trends.

• Accountable for all hospital, professional and ancillary unit cost financial forecasts.

• Achieving all regulatory, accreditation and enterprise network adequacy requirements.

• Meet all geo-access standards.

• Oversees the maintenance of all provider contract lang