Mgr, Medical Cost Mgmt

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

Responsible for managing multiple aspects of the Enterprise medical costs structure including both on-system and off-system medical costs and directly lead efforts across the Enterprise to provide and present meaningful medical cost trend analysis to drive opportunities and decision making. Collaborate with multiple Commercial and Government Program business partners, including both clinical and financial, to drive the Medical Cost Trend Committee with the goal of identifying emerging business trends and the development of medical cost action plans. Key focus areas will include directly managing the Government Programs payment cycle for various provider incentive programs and other value based payment programs including shared risk programs, ensuring that necessary internal controls are implemented and working effectively and Government value based programs are administered within financial expectations, leading the Medical Cost Trend Committee, developing the underlying assumptions and business commitments to support all medical cost budgeting and forecasting activities, and for the financial oversight of the Enterprises Behavioral Health Program.

Responsibilities:

• Direct and drive the Enterprise Medical Cost Trend Committee process and partner with leaders across Analytics, Network, Medical Policy, Clinical Operations and Value Based Programs to review and identify emerging business trends and to collaboratively develop solutions to mitigate trend.

• Partner with the Enterprise Behavioral Health owner to drive financial performance through vendor management, new and existing program design and evaluation, advanced analytics and reporting, network financial management and medical cost action plans. Responsibilities include budgeting, forecasting, operations finance, development of analytics and strategic investment.

• Direct and support HCM&T initiatives throughout the Enterprise related to network initiatives and optimization, medical cost action plan development and validation, vendor return-on-investment evaluation, and value based program evolution and risk transfer.

• Develop the monthly Commercial & Medicare Network Unit Price Model reporting and collaborate with the HCM Network team on identifying drivers of network unit price and the development of network strategic initiatives.

• Own the development, production and continued enhancement of HCM&Ts Monthly Operating Report and partners across the enterprise to report, track and challenge HCM business metrics in order to meet our P&L objectives.

• Direct activities amongst HCM&T partners, Actuary and Finance to develop and validate medical cost trend reporting for the Enterprise budget and forecasting purposes.

• Lead the ownership and credibility for all Incentive and Value Based Program financial, payment and analytical processes for Horizon's Government Programs Division including providing strategic oversight for critical business and technological aspects of the implementation and ongoing administration of these payment processes.

• Lead the analysis and business case development for Horizons Government Programs Divisions Incentive and Value Based contracting arrangements and evaluate the business terms of agreements in support of the negotiation of rates with providers.

• Direct the development of Government Programs value based models to promote the transition of providers into shared savings models and ultimately migrate into shared risk models.

• Manage the Government Programs Value Based Programs reporting for both internal and external customers including the issuance of monthly, quarterly and annual value based reports and payments.

• Identify opportunities to reduce manual processes and interventions and develop systemic solutions to drive efficiency. Accountable for maintaining effective internal controls over the processes and transactions under areas of responsibility including the completeness and accuracy of financial information and transactions, compliance with applicable laws and regulations, and the effectiveness and efficiency of operations.

• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers staff salaries.

Disclaimer:
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.

Education/Experience:<