Mgr, Out-of-Network Optimization

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. BCBSAZ offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

This position requires work and residency within the state of Arizona.

PURPOSE OF THE JOB

Leads strategy to maximize vendor component of out of network claims negotiation and management. Manage relationship with vendor including monitoring performance, addressing regulatory changes, facilitating claims file exchanges,

understanding claims edits related to vendor direction, and administering any future RFPs. Lead cross-departmental efforts toevaluate and pursue opportunities through cooperation and communication. Requires skills in claims analysis (e.g, must understand various pricing methodologies, networks, provider contract status, etc.). Requires skills in claims payment integrity functions and processes.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

1. Required Work Experience

· 7 years of experience with health insurance claims in payment integrity, fraud investigations, and/or operations

· 5 years of experience managing internal projects and cross-functional initiatives

· 5 years of experience in a managerial role (Sr Mgr requirement)

2. Required Education

· Bachelor’s degree in business, finance, or related field

3. Required Licenses

· N/A

4. Required Certifications

· N/A

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

· 10 years of experience in Payment Integrity, Special Investigations Unit

· 10 years of working in a flexible, customer-centric team environment while leading cross-functional initiatives and/or

projects.

· 10 years of healthcare experience or health industry experience

2. Preferred Education

· Bachelor’s degree in business, finance, or related field

3. Preferred Licenses

· N/A

4. Preferred Certifications · N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

· Administer, interpret and maintain current working knowledge of the required BCBSAZ systems and vendor capabilities for the assigned area of responsibility. · Review, update and maintain accuracy of department documentation, computer files, policies and procedures related to the position goals and objectives. · Direct, evaluate, define and improve the quality, quantity and timeliness standards to achieve individual and department performance goals as defined within department guidelines.

· Consult and coordinate with various internal departments, external Blue Plans or business partners and government agencies. Work with stakeholders to assemble collaborations and facilitate partnerships that create value in health care.

· Identify, investigate and resolve any issues with vendor processing or provider payments.

· Ensure file transfers with vendor are timely, reliable, and as seamless as practical.

· Coordinate with Payment Integrity, Payment and Coding Policy, Underwriting, Actuarial, and others as needed to pursue opportunities.

· Direct cost benefits analysis to determine if the functions and activities required to identify, pursue, and post overpayments should be internal or outsourced.

· Ensure changes in vendor claim directions occur in the systems, including pending, adjusting, and releasing the appropriate claims.

· Directly develops business plans and sets financial targets to achieve desired goals.

· Plan and lead complex projects from inception to completion. Includes working independently on creating timelines, working with other areas to define deliverables, monitoring progress, implementing the project and resolving/monitoring post-implementation issues.

· The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.

· Perform all other duties as assigned.

COMPETENCIES

REQUIRED COMPETENCIES

1. Required Job Skills

· Intermediate PC proficiency

· Basic skill in word processing and presentation software

· Intermediate skill in project management

· Working knowledge of classification tools (ICD, DRGs, ACGs, ETGs, etc)

· Intermediate proficiency in spreadsheet, query/data mining, and business intelligence software

· Required Professional Competencies

· Advanced skill in project management

· Superior analytical skills · Strong and effective written, verbal and presentation skills with the ability to collaborate with team members and business stakeholders at all levels of the organization. · Communicate professionally to both internal and external customers · Analytical skills in observing and documenting processes at a detailed level · Proficiency in process improvement and business process design · Analyze and research data, propose solutions to resolve issues · Ability to use a variety of classification tools and manipulate large quantities of data · Flexibility and willingness to adjust to shifting demands/priorities. · Ability and experience to assimilate multiple new functions, services, projects and systems while maintaining existing systems and programs.

2. Required Leadership Experience and Competencies

· Ability to build effective new teams

· Principled leadership and sound business ethics

PREFERRED COMPETENCIES

1. Preferred Job Skills

· N/A

2. Preferred Professional Competencies

N/A

3. Preferred Leadership Experience and Competencies

· N/A

Our Commitment

BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see azblue.com.  If interested in this position, please apply.