Senior Health Systems Contracting Consultant

Capital BlueCross
Washington D.C.
Apr 15, 2018
May 20, 2018
Full Time

Senior Health Systems Contracting Consultant

Capital BlueCross is the leading health solutions and insurance company in Central Pennsylvania and the Lehigh Valley. As a partner in the community’s health for nearly 80 years, we offer health insurance products, services, and innovative technology solutions that provide peace of mind to consumers and promote health and wellness for our customers.

Headquartered in Harrisburg, Pa., this capital city offers something for everyone, including access to the outdoors, with mountains, rivers and streams close by, and shore points within a half day’s drive. Major east coast cities such as Philadelphia, New York, Baltimore, and Washington, D.C. are just a few hours away by car. The area is also bolstered by multiple colleges and universities offering top notch higher education. A lively arts scene is enjoyed in the Harrisburg area as well as a variety of family entertainment venues, including amusement parks and sports arenas that make the area an ideal location for families.

This professional is the strategic expert who develops, modifies, prices and presents the terms and advantages of our products to acute care health system partners, physicians and ancillary providers that utilize the Capital BlueCross network. Responsibilities involve addressing reimbursement details, creating win-win contract terms, product design development based on data/intelligence, and the monitoring of financial analysis/impact of outcomes across partnerships.

This key individual supports corporate Directors with complex contracts and amendments, and will take large responsibility in managing the transformation from the network’s fee-for-service driven model to one that includes value-based programs and products that align with the Triple Aim objectives (improved satisfaction, quality, and cost), to include capitations, risk arrangements, custom needs plans, and MA-VBID models. Will be engaged in the performance of provider incentive programs for STARS and risk adjustment to ensure all providers are performing at 4 STARS or higher.

We're seeking a credible relationship builder who knows the intricacies of reimbursements, POP quality scoring and CMS-led value-based pilots and programs, competitive pricing/cost positioning and budget projections of our company and health providers.

Candidates must have a minimum of a Bachelor’s Degree in business, finance, or a health related field (Master's preferred); 10 years of experience in the health benefits industry; and 5+ years' experience in direct negotiation experience to include all aspects of health system formations including provider categories of professional practitioners, ancillary divisions, and acute care hospitals, or the equivalent payer negotiations experience from within a health system. This leader should also have the ability to coordinate, plan and engage a team in the design of systematic applications of contract provisions in a complex claims processing system. Preferred applicants will possess 2-3 years’ operational experience with value based programs (ACO, PCMH, and Bundled Payments). Must be able to negotiate contract language provisions typically found in Provider Agreements for Commercial and Medicare Advantage markets. Broad knowledge and understanding of the Medicare Program reimbursement methodologies and Medicare Advantage Programs is needed, along with knowledge of the various state and federal licensing requirements and bodies, existing accreditation organizations (JCAH, CARF, etc.) and their criteria.

More than a health insurer, our company delivers innovative solutions through a family of diversified businesses that is creating a healthier future and lowering health care costs. Among these solutions are patient-focused care models, leading-edge data analytics, and digital health technologies.

We offer a highly competitive, market-driven compensation/benefits plan. Capital BlueCross is also committed to providing physical activity and wellness opportunities for our employees. We offer a convenient on-site fitness center, wellness incentives, and access to personal fitness training sessions to help employees meet their health goals. We have been recognized as a 2016 Platinum-Level Fit-Friendly Worksite by the American Heart Association and were named #3 on Training Magazine’s list of the top 125 globally ranked training programs.

Our innovative Capital Blue Health and Wellness Centers located in Enola and Center Valley provide in-person service and inspiration to help people reach their health goals. Each one is open to the public and includes a fitness studio, Healthy You Café and on-site care guides skilled in multiple areas, including nutrition and biometrics screening. Capital BlueCross employees can take advantage of the many services offered at Capital Blue at little to no cost.

Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law. We offer a highly competitive, market-driven compensation/benefits plan. Engage with us on LinkedIn, Twitter, Facebook or Instagram.

Interested and qualified candidates should apply online at

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