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Job Description Summary :
* Provides the overall management and strategic direction to the Provider Contracting, Network Management, Reimbursement, Configuration, Provider Service Operations, and Analytics departments.
* Participates in the development, modification and implementation of complex payment methodologies, from fee for service to value-based reimbursements, for various provider types. Makes recommendations on new methodologies that link quality and price to reduce cost trend. Provides expert knowledge around Hospital, Physician, and Medical Home profiles and reimbursement including: ACO’s, bundled episodic payments, capitation, etc.
* Develops and implements provider contracting strategy to support Plan’s significant contract modernization effort on behalf of Blue KC’s expansive network of hospitals, physicians and ancillary providers.
* Develops and implements expansive BPO (Business Process Outsourcing) strategy for Blue KC key provider service operations function.
* Provides assistance concerning the resolution of complex business and technical problems and communicates complex information and developments to appropriate staff. Serves as point person for issues related to complex methodology issues with providers, and system configuration issues related to FACETS, NetworX Pricer, and NetworX Modeler.
* Handles complex external contract negotiations with all provider types and direct management of vendor relationships and other outside resources. Acts as main point of contact between the vendor and the internal customer. Develops and implements detailed contract negotiation strategy, including face to face negotiations on multiple types of reimbursement methodologies.
* Builds relationships that nurture provider partnerships and seeks broader value-based business opportunities to support the local market strategy.
* Provides project leadership to facilitate the implementation of new complex applications and complex enhancements of existing applications. Serves as project lead on system enhancements in provider services. Provides oversight to team and technical lead on testing and implementation.
* Directs Director(s) of Provider Contracting and Network Development which include teams of managers and provider account executives, provider solutions, reimbursement and analytics, and business process outsourcing managers, that support all hospital and provider related activities on behalf of Blue KC.
* Responsible for developing and overseeing key stakeholder relationships including our broker relationships, provider groups and employer groups as may be connected to Blue KC’s provider contracting strategies.
* Responsible for driving key BCBSA Value Based Contracting opportunities at the local level in order to facilitate national sales account strategy.
* Accountable for implementing trend management strategy to achieve corporate targets to drive affordability and value for groups and members.
10+ year's experience as senior level management and oversight of health plan provider contracting, network management, provider service operations and reimbursement & analytics effort.