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Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
This position is accountable for leading a team of network management staff and managing the Horizon behavioral health (BH) network of ancillary and professional providers supporting the Commercial, Medicare Advantage, and Medicaid lines of business. Position is accountable for strategy development for all aspects of the BH Network and ensuring the team executes accordingly. Responsibilities include, but are not limited to, network adequacy and provider recruitment and contracting, overall compliance with Medicaid BH network requirements, provider communications, establishing contractual relationships including rate negotiations, contract development and execution, ongoing contract management, routine and escalated complaint resolution, project initiative planning and execution, network training and education to promote cost effective quality practice patterns. This position is also accountable to ensure network compliance with regulatory, accreditation and internal policies and procedures. Role is accountable for ensuring plan compliance with State Medicaid contract requirements and value-based contracting.
Responsibilities:
Drives network strategy of BH ancillary facility and professional providers both strategic and tactical. This consists of either full accountability overall strategic activities (including contracting and ongoing performance management/oversight) or a key stakeholder in the strategic initiative accountable for specific goals. Provide strategic leadership and assesses needs and plans for the recruitment of providers to Horizon-s BH network(s). Analyzes membership and geographical access by Specialty to determine specific goals and action plans for acquisition of new BH professional providers and ancillary facilities (including free standing drug and alcohol/residential programs, psychiatric hospitals, PHP's and IOP's), providing a blueprint for contracting priorities. This includes driving strategy of new provider recruitment (both outreach and intake activities). Supports the ongoing expansion and maintenance of the contract relationships for the Horizon MindCare virtual treatment solutions and all value based contracting across all types of providers/organizations. Provides strategic direction and subject matter expertise on new or emerging solutions. Lead all aspects of Medicaid full BH carve-in implementation including network gap analysis, recruitment/contracting/rate setting and prioritization of key provider targets, supporting all network aspects of readiness review, and assuring compliance with all network related contractual and reporting requirements. Provides strategic direction and execution on BH network contract renewals and ensures input is provided that will maximize the potential for retention, including review of financial modeling and directing staff on negotiation approach, adherence to PADU guidelines, conducting network assessment, special services offered and professional and ancillary cost efficiencies and facilitation of recommendations for approval by the BH leadership team. Manages unit price cost targets for both ancillary and professional BH network including establishing budget targets and managing negotiations against targets. Accountable for the results of the BH Network Management Department of designated resources assigned to handle network education, retention, cost management and inquiry resolution for Horizon Network(s). Oversee and drive resolution on high-profile BH provider and ancillary matters, including executive inquiries and escalations in collaboration with other Enterprise SMEs. Direct and oversee standards and service level agreements to ensure goals and objectives are being met, and hold all team members accountable. Provides competitive intelligence around other company-s network and reimbursement strategies as well as internal information around actions already in play that Health and Network Solutions (HNS) and Horizon Behavioral Health are pursuing with specific group practices or ancillary networks. Analyzes key Horizon initiatives (MCAP, delegated vendor arrangements, privileging, etc.), determines the effect they will have on the provider relationship, and manages all communication around these changes as well as presents action plans to address related challenges. Ensure network compliance by directing the design and implementation of effective accreditation, State, Federal and BCBSA mandate requirements impacting Network Agreement(s) and Horizon's policies and procedures. Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures. Develops and monitors goals for staff and provides ongoing feedback and coaching. Responsible for identifying and implementing business process improvements impacting both department and/or Horizon Network(s) to reduce administrative costs. Conducts performance reviews on an annual basis and administers salaries for the staff. Directs the employment activities of the office that include staffing, development, and training. Responsible for the department Administrative Budget.
Disclaimer:
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.
Education/Experience:
High School Diploma/GED required. Bachelor degree in business, finance or health administration preferred or relevant experience in lieu of degree. Master's degree preferred. 10+ years behavioral health provider relationship management, contracting or sales/account management within Healthcare Industry. 5 years supervisory experience. 5 years Behavioral Health experience required.
Knowledge:
Operational knowledge of healthcare industry, industry trends, legislation and compliance, provider office practices, major competitors, hospitals, behavioral health facilities and professional provider specialties in NJ and State and Federal healthcare regulations/legislation.
Skills and Abilities:
Must have excellent verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated management experience with a focus on goal setting and coaching. Exhibits proven leadership, delegation and project management skills. Proven analytic skills and financial acumen, as well as research and problem solving skills a must. Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development. Proven ability to influence without authority and the ability to achieve results through others in a decentralized organization without formal reporting relationships. Strong facilitator skills in leading large teams. Experience in successfully leading cross-functional teams to achieve improvements. Ability to manage resources efficiently. Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities and tasks, deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Proven ability to ask probing questions and obtain thorough and relevant information. Requires excellent interpersonal skills and ability to work with all levels. Requires strong presentation skills. Must demonstrate the ability to effectively present information and respond to questions from all levels within the organization.
Salary Range: $108,000 - $147,420
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
Disclaimer:
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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Horizon Blue Cross Blue Shield of New Jersey
tuition reimbursement
Apr 01, 2025