MCR Support Analyst

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

This full time, dedicated position is accountable for supporting MCAP (Medical Cost Initiatives) through feasibility study, savings analysis, contracting, implementation, post-installation monitoring and monitoring and reporting of actual savings for MCAP initiatives in HCM. These initiatives include but are not limited to delegated vendor management, out-of-network management, recovery, code editing and medical policy integration opportunities that contribute to medical cost savings. This analyst position provides analytical, implementation and reporting support to the HCM MCAP Initiatives Director. This role is expected to lead the vetting, implementation and reporting of multiple Medical Cost Maximization projects and programs for the Enterprise with the expectation of MCAP savings being achieved.Responsibilities:

• Utilizes knowledge, experience, data analysis, market analysis, internal and external relationships to identify and assess opportunities that when implemented will result in MCAP savings opportunities.

• Research market trends and engage vendors to assess opportunities.

• Meet internally with business owners and/or stakeholders including medical economics, actuarial and finance to identify medical trends and medical cost savings opportunities.

• Develop business case which defines current state, opportunity statement and develop recommendations in preparation for stakeholder presentation.

• Collaborates with Vendor, Sourcing, IT Security and Legal in the development of agreements required for external opportunities, ie. BAA, NDA, Demonstration Agreement and 3PRA, MFT, HIPAA Minimum Necessary Certification.

• Collaborates with Analytics, Vendor(s) and Actuarial to gather and compile data requirements and submit data request for opportunity analysis.

• Collaborates with FP&A and Actuarial on financial analysis to develop and validate savings and ROIs.

• Coordinates Solution Options, Planning Approximations and Implementation Timelines with IT BSG and EPMO liaisons.

• Utilize tools to plan, document, store and track initiative artifacts in Excel, MS Project, SharePoint and Planview.

• Plan, forecast, develop recommendation, seek funding for and oversee implementation of changes (including communication plans) within the Medical Cost Maximization, Delegated arrangements and Vendor oversight including, but not limited to:

• Identifies and engages the appropriate IT and Business resources/SME’s to participate in project workgroups.

• As the primary point of contact, sets and maintains expectations of the initiative objectives for the project team and for all involved team members.

• Ensures the right people are involved at the right times for key deliverables such as Business Requirements, Test Plans, Operational Workflows/Support Plans, Training, Communications, Portal Updates, etc. in close collaboration with business subject matter experts, IT subject matter experts, project managers and business system analysts.

• Collaborates with Sourcing and Legal in the development of SOW and participates in contract discussions and negotiations.

• Coordinate and Collaborate with DVOD to develop SLAs and production monitoring process.

• Participates and ensures development of end to end test plans and test cases (SIT and UAT). Assists in root cause analysis and resolution of defects and confirms acceptance of final test results.

• Coordinates/Ensures all communication and training requirements are identified, planned and completed. Assists with the development of Communication Plans (Member and Provider Mailings, Portal Updates, MAC Notifications, etc.) and Training Plans when required.

• Participate and ensures Post Production Support Plans are developed and provides appropriate reviews occur within the agreed upon warranty period. Assists in root cause analysis and resolution of post-production issues and confirms acceptance of operational transition.

• Participates and ensures that Operational Transition Plans, both business and IT are developed and monitored during warranty. Confirms acceptance of operational transition in collaboration with EPMO, BSG, MCAP Service, Vendor and Business Teams.

• Ensures that savings and ROI models are up to date, maintained and aligned with the initiative scope and communicates risks and reflected in the MCAP reports.

• Project Change Requests (PCRs) are documented and ensures that changes to scope and cost are communicated, approved and reflected in the MCAP reports.

• Ensures that the staffing analyses are performed and reflected in the budget/forecasts when add to staff is requested Ensures that the appropriate funding approvals are requested and obtained.

• Complete opportunity and project overviews/status reports on an as needed basis (i.e, PowerPoint Presentations, Executive Dashboards)

• Reviewing and providing input into project stakeholder reviews.

• Participate in the development of enterprise risk management reviews.

• Participate in the development of presentations for Medical Policy, Reimbursement Policy, HCV Vendor Strategy Committee, Delegation and Vendor Oversight Committee.

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 preferred or relevant experience in lieu of degree.

• Project management experience or participation as a key Subject matter Expert (SME) is a plus.

• Requires broad-based experience with a minimum of 5 years in managed healthcare or related industry.

• Successful track record in managing operations with process improvement background desired.

• Claims systems knowledge is preferred.

• Past experience on system implementations in a fast-paced, high pressure environment is preferred.

• Experience with specialty health plan products and vendors preferred.

Knowledge:

• Requires broad understanding of claims systems and related ancillary systems.

• Requires business and/or technical expertise from previous claims projects and work flow changes and impacts.

• Requires knowledge of of a claim processing system such as NASCO system and other ancillary support systems such CareRadius, Ncompass, Sharepoint, Clearquest or other similar systems

• Requires knowledge of project management life cycles and related tools and practices.

• Must have a good understanding of Utilization Management processes, Medical Policy Application, claim processing including pricing .

• Must have strong organizational and analytical skills and demonstrated ability to effectively manage multiple projects at one time.

• Must have strong inter-personal skills with a demonstrated ability to lead cross-divisional work teams.

• Must demonstrate an understanding of the interdependences between the business, clinical and financial side of the health care business.

• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint, MS Project).

• Should be knowledgeable in the use of intranet and internet applications.

• Must have a working knowledge of the impacts of mandates and legislation on overall claims processing and contracting.

Skills and Abilities:

• Requires excellent communication and presentation skills and be comfortable speaking in front of all levels of management.

• Requires technical proficiency in Horizon claims operating models.

• Requires excellent coordination management and organizational skills.

• Requires strong analytical and problem solving skills.

• Require excellent conflict management and relationship management skills.

• Requires excellent facilitation, coaching and platform skills.

• Requires strong project management skills based on Horizon project management practices.

• Requires ability to work on a matrix-managed project team.

Salary Range:

$84,700 - $115,605

​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:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

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.