Description
At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.
Join HCSC and be part of a purpose-driven company that will invest in your professional development.
This position is responsible for directing the functions of Blue Cross and Blue Shield of Illinois' (BCBSIL) provider performance team, and all aspects of provider relations for all BCBSIL networks, including managing and controlling the development, implementation, expansion, maintenance, and operational and financial effectiveness of contracted providers for the Illinois state plan and the border states; directing the functions of delegation oversight activities for IL Provider Networks directing the management of staff responsible for contracting, network management and provider relations for IL Provider Networks; and directing the management of staff responsible for delegation oversight for all IL Provider Networks.Job Responsibilities:
Responsible for provider recruitment, contracting, payment and servicing activities for IL Provider Networks. Develop, implement and maintain procedures for provider participation, network expansion, contracting and service.
Develop corporate strategic planning for new and existing IL Provider Network Programs.
Responsible for directing the management staff over the IL Provider Networks for provider performance to ensure the development, implementation and expansion of appropriate IL Provider Network areas and support for HCSC IL Provider Network and product development.
Analyze networks on a regular basis for provider accessibility and availability to determine appropriate action that will ensure compliance with applicable laws, regulations, and rules and guidelines.
Work closely with Sales/Marketing to assess competitive position of the networks. Analyze provider satisfaction survey results and formulate resolutions for problem trends.
Responsible for directing the management staff over IL Provider Network Provider Relations to ensure operational and financial effectiveness of the IL Provider Networks, including the identification and resolution of issues or complaints, as well as the development of strategies and policies for the ongoing successful management of the IL Provider Networks.
Develop, update and maintain standards for optimal IL Provider Network Provider Relations performance, including guidelines and policies and procedures that work to ensure identification of root cause issues related to provider performance, claims payments, in-person and virtual visits and other relevant areas for optimal Provider Relations excellence.
Develop and monitor an effective communication protocol to keep Network Representatives apprised of new and modified processing or reporting requirements. Oversees provider payment and incentive programs, internal education and the production of provider education materials.
Responsible for directing the management staff responsible for delegation oversight and auditing to ensure applicable regulatory requirements are met. Develop educational tools and programs necessary to achieve these outcomes.
Serve local, regional and corporate committees and task forces as required, including but not limited to the Delegation Oversight Committee and work closely with the applicable compliance and legal teams on all matters related to compliance with State and Federal requirements applicable to IL Provider Networks.
Educate HCSC staff and medical groups/providers regarding corrective action when required, and oversee the completion of corrective action.
Consult with upper level management to determine the adequacy and effectiveness of operations, furnishes advice, and maintains contact with all personnel necessary to conduct multiple complex projects.
Responsible for the evaluation and recommendation of improved management controls, practices, systems, planning, budgeting, and other organizational structures to further enhance high quality corporate objectives.
Develop and implement appropriate training programs for Medical Group or Physician Practice Organizations.
Create and revise network policies, as necessary. Interpret existing and new Government Program standards and coordinate interdivisional projects designed to ensure professional network compliance.
Monitor and coordinate activities of HCSC areas to ensure conformance by HCSC to physician organization contracts.
Coordinate with HCSC areas to ensure development of policies, procedures, assignment of resources and timely implementation for new programs and products.
Collaborate with HCSC Medical Management, Quality Improvement Management and Compliance on programs and activities to ensure all provider agreements, policies and processes comply with applicable CMS requirements.
Keep abreast of developments, particularly competitive activities, to further enhance the delivery and financing of corporate health care services.
Represent the corporation in interactions with CMS and other external agencies and outside health care organizations including, but not limited to, the Managed Health Provider Association (MHPA) and State Association of Health Plans (ex. IAHP).
Represent the department in cross-divisional issues relating to contracting and network management and serve as a primary contact for ITG, SSD, Marketing, and Finance divisions regarding Government Program professional provider relations issues.
Provide network information for the preparation of Requests for Proposals and other HCSC enterprise-wide requests for IL Provider Network information.
Required Job Qualifications:
Bachelor Degree in Business Administration and 15 years of experience in the health care industry.
10 years of experience leading compliance or provider affairs oversight and/or auditing of delegated functions including but not limited to compliance training, claims payment and organizational determinations reporting.
In-depth knowledge of the following:
Professional reimbursement methodologies, including professional and global capitation, risk sharing and incentive plans.
Thorough understanding of government program reimbursement and strategies to ensure revenue optimization including but not limited HCCs and Star performance.
Thorough understanding of relevant legal and regulatory requirements associated with Government and commercial contracts.
Thorough understanding of what it takes to implement and administer provider contracts as negotiated.
5 years in supervisory or management position, with a minimum of 3 years of experience leading compliance, government programs or other provider affairs-related supervisory or regulatory functions.
Negotiation skills and a thorough understanding of the health care delivery system to include hospitals, IPAs and ancillary providers.
Knowledge of alternative methods of delivery and financing health plans.
Knowledge of capitation and professional group practices.
Ability to lead, motivate and produce high end results.
Clear and concise interpersonal, verbal and written communications
*This is a hybrid role, in the office 3 days/week*
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HCSC Employment Statement:
We are an Equal Opportunity Employment / Affirmative Action employer dedicated to providing an inclusive workplace where the unique differences of our employees are welcomed, respected, and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.
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