Position Description

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.”

The Provider Engagement Consultant is the primary liaison between key network providers enrolled in alternate payment models, risk revenue programs, and high value primary care and specialty provider types that drive quality and cost of care outcomes. This role is responsible for orientation, continuous training, and education to the provider network with a focus of provider performance and the implementation of strategic initiatives that support quality, cost, and satisfaction. Directly responsible for analyzing and communicating performance reports (Medicare STARs, HEDIS, Leapfrog, Risk Adjustment, Cost Trends; and other performance areas affecting the company's overall performance such as; Appeals, Claims Operations, and SIU cases to internal and external stakeholders - including practices and facilities. This role will assist with the recruitment of providers within the network and into alternate payment models. The role will provide strategic and operational input for network development to ensure members have access to quality, cost effective care.

Responsibilities and Qualifications

• Conduct provider orientation, continuous training, education, and assistance to the provider network to encourage their engagement of company programs and policies. Is responsible for assessing the needs of each practice or facility to drive network engagement and ensure each practice or facility delivers high quality, cost effective outcomes that meet the strategic objectives set by the Organization. Participates in the development and presentation of instructional materials for internal and external audiences.
• Analyze performance reports and data to inform process interventions, trends, and identified opportunities with the provider network. Dissemination and interpretation of quality and efficiency reports, as well as, program results. Monitors and develops improvement opportunities for HEDIS, STARs and coding - inclusive of engaging stakeholders for any audit requirements. Collaboratively works with practice or facility to develop action plans to drive performance improvement efforts. Provides assistance to practice and facility in the use of analytic and population tools or data; and directly engages providers in discussions to enhance the integration of all supplemental records and data files.
• Functions as the organization’s representative subject matter expert to providers in value-based reimbursement programs for both commercial and government business (CHIP performance, FEP performance, Medicare STARs, HEDIS, and risk revenue), as well as, general provider performance.
• Communicates and is a liaison between the provider and facility, and the organization for compliance with Company’s policies and procedures. Provides education and training to provider network related to provider trends from claims, appeals, quality of care, and contracting questions/issues and incorporates any trends into performance improvement action plans.
• Provides operational input for network development and servicing to ensure members have access to quality, cost effective care and that the Plan appropriately and timely responds to any member issue. May be a team member for corporate projects related to provider innovation and alternate payment models, as requested.

Skills:

• Must be able to lead and motivate individuals and organization within an ever-changing environment. Demonstrated character, competence, and courage to have the social influence in which they can enlist the aid and support of others in the accomplishment of departmental and corporate objectives. Builds and maintains valuable business relationships in a face-paced environment.
• Strong decision making, problem solving, and customer presentation skills (verbal and written). Must have aptitude for a highly visible position demanding integrity, uncompromising professionalism, and conflict management. Ability to analyze complex problems and issues, determine impact, and develop business solutions or recommendations for changes. Ability to build and maintain valuable business relationships in cross-functional, fast-paced environment. Strong written and verbal communication skills. Ability to prepare written materials and oral presentations for internal/external audiences with a wide range of interests and responsibilities. Includes ability to lead meetings and to develop teamwork and use collaboration, consensus-building, and negotiation skills to advance strategic BD initiatives in a meeting setting. Familiarity with the Plan operations and the interrelationships of Plan operations (e.g., claims processing, rating, billing, etc.).

Knowledge:

• Knowledge of current and emerging communication strategies. Knowledge of alternate payment models and BCBSA strategies regarding Blue Distinction. Ability to quickly gain knowledge of new business processes and issues. Adept at using Microsoft Office Suite of products (such as Word, Access, Excel, Power Point, Outlook, etc.), Microsoft Project and Visio.

Experience:

• A minimum of 5 years progressively increasingly responsible experience in health insurance or related field. Desire experience in Medicare and Commercial insurance with experience in risk revenue, healthcare administration in primary care, or population health management.
• Experience with behavioral health preferred.

Education and Certifications:

• Bachelor’s degree required in business, clinical, or healthcare industry discipline. In lieu of Bachelor’s degree relevant experience for 8 years is required.

Work Environment:

Work involves periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

Physical Demands:

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.

Location:

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays. 

Other:

• Travel Amount (40% of time). Current valid Pennsylvania driver license, reliable source of transportation, and willingness to travel within service area to engage with provider network.

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.