Mgr, Medical Cost Initiatives

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

Job Summary:

The position will have chief oversight and coordination responsibility for physician outlier audits performed by internal and vendor resources and the prepayment reviews which will be performed by a variety of vendors. The scope of responsibility is directly linked to an annualized Medical Cost Program goal and these audits contributing annually to payment integrity savings supporting a positive trend on our medical cost spend. The position will oversee an annual budget in excess of $5M. Additionally this position will have day to day oversight of internal and vendor team member to ensure compliance with all legislative and regulatory standards. The positon will coaches and guide team members; measures and calibrates individuals performance against goals and recommend annual merit and AIP awards.

Responsibilities:

• Provides direct leadership to team within Health and Network Solutions (HNS) comprised of Horizon employees and dedicated vendor staffing; coaches and guides the team to ensure optimal performance supporting meeting key performance metrics.

• Measures and calibrates team member performance against goals, conducts annual performance reviews and recommends annual merit and incentives commensurate with the same.

• Provides input to annual budget development and quarterly forecasts and completes monthly accruals.

• Oversees day to day vendor performance:

• Ensures vendors remain compliant with legal and Horizon requirements including but not limited to data security and governance; support contract negotiations. 

• Oversees vendor performance to ensure performance against SLAs and as required overs remediation plan development and application.

• Coordinates RFP with Procurement to ensure maximization of vendor capabilities as appropriate

•  Ensures accuracy of invoicing.

• Provides timely and accurate reporting including but not limited to:
  •    Monthly Key Performance Indexes 
  •    Monthly MCAP reporting
  •    Quarterly PI reporting
  •    Monthly accruals

• Oversees integration of Engagement Action Plans support Horizon’s Culture of excellence driving improved engagement results for their team.

• Evaluates and modifies workflows and automation capabilities to enhance efficiencies allowing for expanded audit capabilities both across LOBs and audit types.

• Implements new MCAP programs directly related to outlier audits to ensure realization of additional savings and payment integrity.

•  Drive Request for Information to ensure Horizon secures best vendor partnerships in support of audit efforts.

• Represent and act on behalf of director in director’s absence.

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

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:

• High School Diploma/GED required.

• Bachelor degree preferred or relevant experience in lieu of degree.

• Requires minimum of 3 years managing high performing teams and in lieu of that 3 additional years’ experience is required in working cross functional on large initiatives. 

• Requires minimum of 3 years’ experience of successfully managing vendor partners.

• Requires minimum of 2 years of demonstrated experience in major project implementations and demonstrated ability to manage multiple projects at once.

• Requires demonstrated ability to accurately assess and ensure compliance with mandates; laws and regulations.

• Requires experience supporting PI capabilities across all lines of business.

• Prefers experience in analysis of medical cost trends.

Additional licensing, certifications, registrations:

• Prefers Audit Certification

Knowledge:

• Requires in-depth knowledge on healthcare billing and claim processing.

• Requires clear understanding health care benefits.

• Requires working knowledge of claim platforms (NASCO and FACETS, preferred).

• Prefers demonstrated knowledge linking business, technical and legal requirements to mitigate risk.