Prepares written cases for binding arbitration by completing a written justification on how HBCBSNJ adjudicated the claim, including but not limited to, member benefits, contracts, payment methodology, policies and procedures.
Establishes a management process with the specific purpose of identifying and challenging medical cost performance through the evaluation of business metrics including utilization and unit cost trends.
Establish a daily pharmacy dashboard report which outlines the status of multiple pharmacy key metrics which will allow for immediate identification of any potentially aberrant claims, financial activity or any system operations integrity issue.
Horizon Blue Cross & Blue Shield • Hopewell, NJ and 3 other locations
Formulates, approves and implements corporate policies as necessary and commensurate with good business practices to ensure the overall effectiveness of the organization and compliance with regulations.
Collaborates and partners with other functional areas impacted to effectively troubleshoot complex claim situations, program/policy disputes, executive, VIP and Regulatory escalations to lead resolution end to end to improve the member experience.
Develop Medical Director competencies, as appropriate, with regard to network management and executive decision-making skills, including establishing and maintaining relationships with hospitals, physicians and ancillary providers.
Engages and collaborates with business, clinical and care delivery leadership at our value-based partners to understand their needs, challenges, and capacity around value-based, accountable care delivery.