Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
This Specialist will support the Provider Account Manager with establishing and fostering collaborative, trusting provider relationships to drive improved provider satisfaction and performance. This position will help drive execution of key support deliverables, be a data SME, and ensure project work plans are executed resulting with high-quality deliverables. Responsible for the end-to-end provider experience maintaining effective relationships with all facets of the provider (Hospital, Professional and Ancillary) community, including provider education, facilitation and resolution of complex urgent problems and data integrity maintenance. In addition, where the provider is a value based partner, this position will serve as a key support between Horizon and value based partners through activities related to supporting the integration of the Value-based Partnership, Care Delivery Transformation, Health Affairs, Analytics and other areas, as necessary, to help achieve and advance Horizon’s value based programs and partnership goals. This person will be expected to effectively collaborate within cross-functional teams internally and externally.
This position will manage triage and intake provider questions and issues; onboarding, training and education of providers; review of performance data with provider groups; and overall provider account management activities. This position will collaborate extensively across the Horizon enterprise with other departments and leaders who are responsible for various aspects of network provider interactions and support functions.
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Cultivate strong relationships with healthcare providers and payment arrangements by understanding their needs, addressing concerns, and providing support and guidance.
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Deliver exceptional customer service by fostering positive relationships, promoting collaboration and ensuring delivery of high-quality services that ensures both provider and patient satisfaction and retention.
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Create, build, and maintain positive, trusting, productive and mutually beneficial relationships with internal Horizon teams as well as external vendors and partners (for example, Braven Health) with strategic partnerships to support our joint goals.
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Maintain a strong understanding of Horizon operations and processes, including contracting, provider data management, credentialing, claims, and service operations.
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Performs activities that develop prospective relationships with providers by supporting and participating in the recruitment and maintenance of the provider network and improve access and network adequacy.
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Provides feedback and input in contracting process to improve the services that will maximize the potential for retention and initial provider enrollment.
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Collaborates closely with Medical Leadership and network physicians to facilitate dialogue pertaining to practice patterns and cost effective healthcare delivery by developing expertise in Utilization Management reporting, monitoring reports, and physician quality measures.
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Educates, monitors, analyzes, documents and interacts with physician and other health care professionals to ensure cooperation, understanding, and effective participation in Horizon BCBSNJ products.
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Alerts and escalates to leadership in a timely manner any potential issues and opportunities found through physician interactions.
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Collaborates with Provider Education & Communication team to present seminars, conventions, speeches, etc. to various physician and other health care professionals, billing services, medical societies and internal groups.
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Provides ongoing support and resources to help providers stay updated with industry changes and best practices .Drives communication with pertinent staff and managers to ensure that interdependencies between the departments, other projects and functional work are accurately identified and addressed, and provides status reports to management.
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Triages, researches, addresses, tracks and trends provider questions, issues, and critical concerns when applicable.
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Initiates communication with other members of the Physician Relations team and representatives from appropriate areas to effectively troubleshoot complex claim situations, program/policy disputes, executive, VIP and Regulatory inquiries to drive resolution and improve service quality.
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Leads internal & external meetings to review and discuss and resolve provider concerns and goals.
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Manages and supports cross-functional teams within a matrix reporting structure to define a collaborative engagement strategy, develop solutions and prioritize core work areas.
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Resolves provider inquiries through research and collaboration with all appropriate stakeholders.
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Maintains a tracking grid that assists leadership in identifying trends to help facilitate cross-functional solution and process improvement(s).
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Works with Leadership to communicate outcome of inquiry to appropriate internal and external stakeholders.
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Researches, recommends and implements potential saving opportunities for the delivery of cost-effective and quality care that subsequently results in the generation of cost savings.
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Understand the basic fundamentals of value-based care programs.
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Responsible for maintaining dashboards on value-based performance, patient outcomes, and financial metrics to identify trends and opportunities for improvement. Presenting findings and recommendations to management.
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Accountable for supporting the integration of the Value-based Partnership, Care Delivery Transformation, Health Affairs, Analytics and other areas, as necessary, to help achieve results within our value-based programs and partnerships.
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Foster high integrity relationships and drive successful implementation of patient-centered provider agreements with the goal of improving quality, cost, and service to members.
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Drive successful implementation of our innovative provider agreements, which are new models of reimbursement and care delivery.
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Work with internal leaders in developing and implementing alternative payment models to support delivery system transformation.
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Evaluate trends and performance data, including total cost of care and quality metrics, to identify key performance drivers and improvement opportunities.
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Support critical network activities including demographic updates, re-credentialing, contract renewals, and training.
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Create and maintain provider onboarding and orientation materials.
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Serves as the key external-facing member of cross-functional/divisional team of designated resources assigned to manage all aspects of Affiliation, Reimbursement, Education, and Inquiry Resolution for all physicians within specialty team.
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High School Diploma/GED required.
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Bachelor degree preferred or relevant experience in lieu of degree.
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Requires a minimum of 3 years’ experience in healthcare industry, including knowledge of healthcare delivery systems, medical terminology, reimbursement processes, and regulatory requirements. Familiarity with healthcare provider networks and the dynamics of working with healthcare providers is essential.
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Requires a minimum of 3 years’ experience in successfully collaborating with cross-functional teams to achieve improvements or relevant experience in lieu of 3 years’ experience.
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Requires a minimum of 2 years’ of experience trouble shooting complex service inquiries.
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Requires a minimum of 3 years’ demonstrated proficient experience working with external accounts, clients or provider partners. This includes managing client relationships, understanding client needs and providing exceptional customer services.
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Preferred contracting knowledge.
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Preferred prior Provider experience.
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Preferred experience in health care cost data review and interpretation. Understanding of financial concepts related to health care provider reimbursement, such as fee schedules, billing and payment processes.
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Strong organization skills are mandatory .
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Demonstrates ability to assist in all aspects of the Provider Experience team.
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Demonstrates ability to create, develop, and maintain business relationships in the Provider space.
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Proven ability to exercise sound judgment.
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Proven ability to ask probing questions and obtain thorough and relevant information
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Familiarity with healthcare information technology systems, electronic health records (EHRs), and healthcare data management. Experience in utilizing technology to streamline processes and improve provider engagement is advantageous.
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Preferred project management skills and ability to manage multiple projects and initiatives simultaneously, ensuring timely and successfully completion.
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Must be detail oriented with strong organizational skills. Proven ability to follow detailed instructions is essential, along with proven problem solving skills.
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Demonstrates flexibility and adapts to multiple responsibilities encompassing multiple areas within the organization.
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Must demonstrate the ability to effectively present information and respond to questions from groups of managers, clients, customers.
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Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
