Position Description:
Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”
This role is responsible for defining, designing, building, and producing deliverables focused on the provider network to meet the demands, objectives, analytics, and reporting needs with a focus on the measurement and identification of total and unit cost expenses, discounts, and trends. These direct responsibilities include deliverables that impact contracting initiatives in Capital Blue Cross’ provider partnerships including total cost of care, value-based programs, triggers and alerts for provider contracting, and discount optimization. The individual is responsible for providing information to be used to evaluate and support strategic, longer term business directions and decisions.
Responsibilities and Qualifications:
- Preparation and completion of data specifications, modeling, and analysis with a focus on provider network cost of care activities encompassing Capital’s total book of business and subpopulations at the various defined market segment, regional, and provider specific levels to examine utilization and cost trends; provider discount performance; reporting and data analysis for medical value and value-based provider contracting to support the provider contract negotiations, monitoring and settlements. Ensure that timely and accurate information is available for the Healthcare Delivery and Provider Partnerships leadership and staff members considering relevant issues concerning data and the provider have been reviewed and addressed.
- Responsible for both independently completing and teaching, instructing and mentoring team members toward the successful delivery of the design, development and implementation of tools, analysis, and research on the cost and utilization trends relative to book of business, market segment, region, product, program, network, employer group, etc. and the communication of this information to key internal and external stakeholders. Ensures that rigorous research design, comprehensive data collection and sound statistical methods are applied to trends, forecasts, projections, corporate reporting, programs, and corporate projects. Provides Plan support for other analytical and reporting needs, trend analysis, financial improvement plan monitoring, compliance and regulatory reporting coordination. Individual will be independently responsible for a number of projects and performing retrospective trend analysis, prospective forecasts, business requirement gathering, customer needs assessments, documentation of data needs/source mapping, competitive and industry research.
- Participate, collaborate in and sometimes lead engagements with other business areas and customers, such as: external customers, providers, sales, marketing, population health management, utilization management, provider partnerships, actuarial, finance, and pharmacy services with a focus on being a subject matter expert providing technical and business level of involvement to support information needs in the analytical and decision-making process. Focused on projects collaborating with business areas or external customers where a proficiency in business knowledge exists.
- Assists business areas in the initial assessments, requirements, project plans, solutions, research and selections with a focus on data, information reporting, and analysis. Lead project task execution by ensuring progress, organizing project data, and coordinating team meetings. Provide information to customers/clients in development of engagements, materials, events, initiatives, committees, and presentations by gathering needed information and using appropriate frameworks and models in the development and assessment of materials.
- Serves on corporate committees, work groups, and teams as necessary to provide input and support on corporate initiatives.
Skills:
- Demonstrated ability to analyze problems issues, outcomes, determine/estimate/project impact and provides or recommends business solutions.
- Demonstrated strong oral, written and presentation skills.
- Experience with Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, Tableau, PowerBi, or other software used for both analytic and reporting functions.
Knowledge:
- Experience with population-based analysis, health care financial trend analysis, modeling, and a background in research methodologies and statistics.
- Knowledge of managed care insurance and business processes, data, systems, and applications for claim payments, network and provider contract administration and management, population management.
- Familiarity with regulatory changes impacting provider reimbursement and operations.
- Familiarity with current corporate structures for health care entities.
- Ability to collaborate and understand the interrelationships of Capital operations (i.e. claims processing, rating, billing, account administration, sales, etc.)
- Familiarity with benefit coverage designs.
- Familiarity with operational aspects of various provider types.
Experience:
- Minimum of five (5) years of experience with health services research, consulting, outcomes research, healthcare economics or epidemiology or within business/customer areas.
Education and Certifications:
- Bachelor’s degree required in one of the following: mathematics, statistics, business administration, health planning and administration, finance, economics. In lieu of a bachelor’s degree, 10 years relevant experience required.
About Us: We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.
