"Alerted.org

Resp & Qualifications

PURPOSE:

This position is primarily responsible for preparing and maintaining fee schedules for plans that utilize the DC Medicaid reimbursement schedules and methodologies. This position may request to extend that knowledge across other Commercial, Medicare and Medicaid plans as needed. This may also include assistance with financial analyses used in the development of reimbursement policy, strategies, cost of care impacts and workflows associated with healthcare providers' reimbursement fee levels. The incumbent will develop recommendations and prepare competitive analyses to include industry, regional, and internal benchmarks as needed. Research Federal, state and local reimbursement trends and mandates to prepare reimbursement recommendations for management.

ESSENTIAL FUNCTIONS:

+ Analyze CareFirst's new and existing reimbursement arrangements/networks and assist management in the development of fee schedules, payment policies, strategies, and workflows associated with healthcare providers reimbursement levels. Work with the various teams to develop contracting and reimbursement strategies that will result in the creation of cost-effective networks and fee schedules.

+ Maintain familiarity with all federal and state provider reimbursement regulations and ensure CareFirst's reimbursement is in compliance with these regulations. Identify potential audit and/or contract compliance issues and recommend strategies to Division management for resolution. Create and maintain confidential databases used for reimbursement analyses to support CareFirst corporate position.

+ Provide feedback on payment policies related to Medicaid and/or Medicare processing. Participate in workgroup projects around clinical editing. Create, maintain and communicate policies as need to support.

+ Use statistical analysis on large amounts of data to develop detailed financial impact analyses as part of financial models for negotiations with professional and institutional providers. Participate in negotiations with high profile providers to provide critical analytical support to Contract Managers and explanations of reimbursement methodologies to providers. Summarize the findings in a concise manner and develop business cases supporting any proposals which will be submitted to Division management for review and approval.

QUALIFICATIONS:

**Education Level:** Bachelor's Degree in Healthcare Administration, Business Administration, Finance or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

**Experience:** 5 years doing financial analysis/modeling in the field of health insurance or health care.

Preferred Qualifications:

+ An MBA, CPA license or other graduate degree.

Knowledge, Skills and Abilities (KSAs)

+ Detailed expertise in DC Medicaid reimbursement.

+ Knowledge of Maryland Medicaid and Medicare reimbursement.

+ Excellent verbal and written communication skills.

+ Excellent PC skills including advanced level knowledge of Microsoft Access, Microsoft Excel, and Microsoft Word.

+ Analytical and mathematical aptitude and have the ability to manage multiple tasks at the same time while prioritizing projects in order to accomplish departmental and corporate goals and objectives.

+ The ability to work independently and accomplish tasks within tight timeframes.

+ The ability to develop financial models/impact analyses and recommend action to management based on the results of those models.

+ Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

**Salary Range:** $60,408 - $119,977

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Provider Payment and Regulator

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

\#LI-NH2

REQNUMBER: 21268