Dir, NSA Program Mgmt

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.

Responsibilities:

• Serve as the OON Surprise Bill point of contact for incoming and outgoing special inquiries from Government Affairs, DOBI, NJAHP, Employer Groups and others in doing so develops and maintains positive relations with regulatory agencies, contractors, accounts and other applicable parties; Partners with Legal to proactively identify and resolve issues of non-adherence to the NSA mandate requirements by providers, arbitration vendors, or other parties.
• Accountable for all resources within the areas of operational responsibility to ensure standards are exceeded for customer service, financial management and regulatory compliance. Internal customers include employees at all levels within the organization, including system leadership. External customers include vendors and providers.
• Present key initiatives to executive leaders and stakeholders and implement as appropriate. Prepares and solicits funding for special initiatives and develops and oversees the program development/department budget in conjunction with corporate goals and objectives.
• Serves as the operational owner for all out of network provider pricing arbitration and negotiations.
• Responsible for the reporting, analyzing and identifying of trends related to OON Surprise bill. Addresses any changes in provider's billing practices and works with internal business partners implement strategies to address them.
• Serves as the business owner for the maintenance of OON Surprise Bill Claims system logic, including automation tools and NASCO Claims processing logic.
• Reviews analyses and reports of various activities to determine department progress toward stated goals and objectives.
• Reviews, prepares, analyzes, and presents reports and recommendations to senior management regarding program results and/or other applicable areas of interest in order to provide concise and accurate information that aids in decision-making.
• Develops, reviews, and monitors service and financial outcomes using performance metrics.
• Responsible for preparing a monthly claims report which is submitted to the Director of Specialty Claims and Services, and VP of Enterprise Claims. This report is used in monthly discussions with Finance regarding claims trends and exposure associated with OON Surprise claims.
• Accountable for all resources within the areas of operational responsibility to ensure standards are exceeded for customer service, financial management and regulatory compliance. Internal customers include employees at all levels within the organization, including system leadership. External customers include vendors and providers.

Education/Experience:

• Education- Bachelor's Degree in related field required or equivalent work history.
• Minimum of 8-10 years healthcare experience including managing large teams, including In-depth experience in health plan operations with direct experience in claims, pricing, billing and provider negotiations

• Requires demonstrated experience in leading operational and execution teams

Knowledge, Skills and Abilities:

• Demonstrated ability to drive resolution to complex problems
• Excellent communication and presentation skills
• Effectively creates, develops and designs presentations and reports, and presents information to/facilitates discussions with internal management and external partners
• Subject matter expert in the NSA and is knowledgeable of CMS and State of NJ NSA requirements
• Read, analyze, and interpret industry and market articles, financial reports, and legal documents.

• Define problems, collect data, establish facts, and draw valid conclusions

• Requires demonstrated experience to communicate successfully internally and externally with all levels of management, including those at the highest level of the Organization. (ie: C-suite and Commissioner at DOBI)

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

Salary Range:

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

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.