Network Specialist at Horizon Blue Cross Blue Shield of New Jersey in Hopewell, New Jersey

Job Description:

Job Summary:

This position is accountable for physician outreach, relationship management, issue identification and resolution, and problem avoidance. This is achieved by serving as the primary member of a team made up of people from various functional areas in the end-to-end provider experience process and is responsible to support the team for the benefit of the providers assigned to the pod/team. This includes maintaining effective relationships with all facets of the physician community, including physician education, facilitation and resolution of complex, urgent problems and data integrity maintenance. This position will identify opportunities for savings, utilizing tools such as claims paid reports, utilization management reports, physician profiling data and referral pattern data. This position is responsible to work directly with network physicians to identify referral alternatives, to provide education, and to track cost savings outcomes.

Responsibilities:

* 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.

* Analyzes membership and geographical access by Specialty to determine specific goals and action plans for acquisition of new physicians, providing blueprint for physician contracting priorities.

* Performs activities that develop prospective relationships with providers by supporting and participating in the recruitment and maintenance of the provider network. Provides input to contract renewals to improve the services that will maximize the potential for retention and initial provider enrollment.

* Develops and implements segmented or tiered relationship strategies and activities that involve an end-to-end provider perspective.

* Informs and educates providers and physicians on Horizon-s products and services and is held accountable for accelerating the physician adoption of related Horizon initiatives.

* Analyzes provider related information and data in order to recommend actions and solutions to strengthen the provider-s relationship with Horizon.

* Leads the development of electronic marketing and educational materials customized to target providers, office managers and their staffs, etc.

* Educates, monitors, analyzes, documents and interacts with physician and other health care professionals to ensure cooperation, understanding, and effective participation in Horizon BCBSNJ products.

* 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.

* Alerts leadership to potential issues and opportunities found through physician contact.

* Plans, organizes, and presents seminars, conventions, speeches, etc. to various physician and other health care professionals, billing services, medical societies and internal groups.

* Maintains a thorough knowledge of healthcare industry trends and developments through the review of industry publications, newsletters and formal training.

* Identifies 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.

* Works closely with Medical Leadership and network physicians to facilitate dialogue pertaining to practice patterns and cost effective healthcare delivery by developing expertise in UM reporting, monitoring reports, and physician quality measures.

* 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.

Knowledge:

* Requires knowledge of healthcare industry.

* Requires knowledge of New Jersey physician community.

* Prefers knowledge of HBCBSNJ programs, products and procedures.

* Requires strong PC skills including Microsoft Office and Outlook.

Skills/Abilities/Functional Competencies:

* Presence and Professionalism:

o Exhibits confidence and professionalism, communicates effectively using all mediums and to all levels of audience.

o Listens actively, speaks and writes clearly, and engages in productive dialog, cultivating credibility and respect of the listener.

* Relationship Building:

o Develops and maintains key relationships.

o Develops and maintains external and internal relationships, engaging appropriate individuals to meet needs. Operates across organizational boundaries while respecting and leveraging local priorities, practices, systems and cultures.

* Business Acumen:

o Understands the up-to-date industry landscape.

o Follows the top strategic, business, technical and physician specialty trends, both short and long term; anticipates and communicates business implications. Familiar with financial variables at the industry, provider and payer levels with particular insights into the financial model of physician practices.

* Analytics and Problem Solving:

o Approaches problems through data and experience

o Frames problems to reveal patterns, isolate root causes and generate practical solutions. Guides and participates in discovery, analysis and thoughtful identification of solutions. Understands the division of activities across functional lines, and how process and system integration can improve performance and enhance provider experience.

* Teamwork and Process Thinking:

o Aligns Horizon demand with provider capacity to deliver.

o Collaborates closely with peers on other teams, and in other departments. Introduces the end-to-end perspective, with members and providers as `customers-, into product and project planning, design and delivery. Takes a cross-functional, integrated view of provider services and articulates future state work flows including inputs, work flow, resources, outputs and measures. Anticipates and resolves potential issues to avoid downstream problems and optimize the provider experience.

* Organizational and Project Management Orientation:

o Handles multiple projects through planning, organizing, and independently following logical priorities.

o Innately understands the significance of resolving different items and what priority level will bring the most value. Is able to organize work, understand details, and move internal -levers- in a fashion that is transparent and unobtrusive to the customer.

Education:

* Prefers a Bachelor's degree in business, marketing, communications, healthcare administration or other related field.

Experience:

* Requires a minimum of five (5) years healthcare experience, preferably with provider or client focus/interaction.

* Prefers marketing or sales experience in the healthcare/insurance industry.

Travel (If Applicable):

* Occasional travel throughout the state of NJ may be required.

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

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.

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