Associate Director, Out of Network Operations

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Th Role:

The role of the Associate Director, Out of Network (OON) Operations is a highly visible leader that will drive measurable incremental value to the organization and our customers in the form of medical claims and administrative cost savings. This includes ongoing management of existing OON programs as well as leadership oversight related to the No Surprises Act (NSA) of the Consolidated Appropriations Act. This position will also play a lead role externally with software and solution vendors, on the management, evaluation and implementation of multiple programs supporting out of network reimbursement.

Key activities and responsibilities include:

• Reporting to the Director, Contracted Health Services, this individual will be accountable for developing program vision, features, functions, and delivering customer and market impact of existing OON programs. The successful candidate will demonstrate a unique blend of leadership, domain expertise, business acumen, creativity, business judgment, industry knowledge, and analytical knowledge.
• Business owner for all aspects of Out of Network payment integrity claims pricing with vendor partners that increased claims savings to the company of close to $600M per year.
• Develop and manage all aspects of the data exchange, invoicing, reporting and analytics with vendor partners.
• Continuously monitor, measure and improve programs and processes that increase efficiency and reduce costs.
• This individual will have responsibility for managing BCBSMA’s compliance with the NSA and performing analysis to support or modify NSA strategy as needed.
• Use experience and business acumen to prioritize opportunities and develop strategies and implement processes to decrease costs, improve program performance and support long term success.
• Business owner for the OON pricing performed by the external Medicare pricing vendor.
• Provide expertise in future internal and vendor OON strategy including design, implementation and management of processes to close pricing gaps and increase claims savings.  
• Manage parallel processing on multiple platforms while smoothly migrating to a streamlined process on a single platform.
• Lead team of two business analysts.

Additional Responsibilities

• Manage existing OON shared savings programs that generate over $75M in revenue to BCBSMA each year.
• Provide SME guidance to Finance and Account Reporting for standard and ad-hoc reporting requests and customized shared savings solutions for certain key accounts.
• Manage research and communications to Accounts, Providers, and Sales for detailed analysis on high volume or high cost provider or member claims.
• SME for answering expanding list of out-of-network (OON) RFP questions from brokers and accounts.
• Continuously Identify and develop opportunities for claims savings or increased program efficiency.
• Lead multiple cross functional teams that may include HMM,  ET, claims operations, finance, sales and legal departments.
• Manage ongoing internal and external operations workgroup meetings with Claims Operations and vendor partners to monitor and improve existing and future claims processing.
• Manage all aspects of NSA negotiation and independent dispute resolution (IDR) processes.
• Develop and maintain reporting for Network management to reduce the use of OON providers at Network facilities and proactively reduce NSA IDR disputes.  
• Respond to and operationalize all BCBSA guidelines related to claims processed locally. Partner with Finance and Claims ops to manage the NSA claims for BCBSMA members outside of MA.
• Support all BCBSA, State and Federal required reporting including non-quantitative treatment limitations (NQTLs).
• Develop all OON and NSA program management reporting including budget estimates, trending, savings opportunities, MA provider usage, out of state pricing and opportunities for improvement.

Qualifications (Knowledge, Skills and Abilities)

• Demonstrated knowledge and understanding of the health care industry, specifically related to reimbursement of healthcare services.
• Strong understanding of strategic and operational planning concepts and methodologies.
• Long-range planning skills and ability to integrate with short-term activities.
• Ability to effectively plan and facilitate organized and productive meetings/workgroups.
• Demonstrated leadership skills in team and/or group settings.
• Proven ability to effectively collaborate with many different levels within the organization.
• Ability to engender trust and confidence with a high sense of