Mgr, Network & Physician Contracting

100 Horizon Healthcare Services, Inc; Hopewell (NJ); On-site; USD 110,000 - 150,000; Full time

Job summary

Horizon Blue Cross Blue Shield of New Jersey seeks a managerial professional to lead the development, negotiation, management, and maintenance of provider contracts across physician organizations, hospitals, and ancillary facilities.

The role involves leading network contracting strategy, negotiating contracts per reimbursement standards, ensuring policy adherence, and driving multi‑million dollar cost savings while supervising contracting staff.

Qualifications

• Bachelor’s degree preferred or equivalent experience.
• Minimum 5 years of business experience in hospital and provider group finance and/or managed care network development.
• Minimum 5 years of knowledge and experience with contract finance and reimbursement methodologies (FFS, Medicare DRG/APC, Medicaid pricing, capitation, full risk, shared savings, incentive arrangements).
• Minimum 5 years of experience leading cross‑functional teams to achieve improvements.
• Minimum 5 years of provider experience in Commercial, Medicare, Medicaid, and Value‑Based programs.
• Minimum 3 years of health care cost data analysis and technical document writing.
• Minimum 3 years of supervisory experience and/or leading people by influence.

Responsibilities

• Lead or support the development and execution of network contracting strategy, including adoption of value‑based contracting for fee‑for‑service providers.
• Negotiate and manage contracts in accordance with Horizon reimbursement standards and key controls.
• Assist and implement provider contracting policies and procedures consistent with industry best practices and regulatory requirements.
• Ensure accurate implementation of contracts, maintain contract language and templates, and interface with matrix partners for network implementation.
• Coordinate across departments to report provider file maintenance requests, claims stops, and new hospital implementation.
• Adjudicate technical inefficiencies related to system‑wide claims, configuration, and provider mapping discrepancies.
• Conduct research, root‑cause analysis, and effectiveness reports to address operational deficiencies and improve efficiency.
• Implement industry initiatives and programs to achieve multi‑million dollar medical cost savings.
• Maintain provider catalog data, credentialing, recredentialing processes, and regulatory standards compliance.
• Provide leadership, training, goal setting, performance reviews, and salary administration for contracting staff.
• Represent the organization at industry conferences, webinars, and other events.

Skills

Leadership

Analytical thinking

Communication

Problem solving

Detail oriented

Cross-functional collaboration

Relationship building

Education

High School Diploma/GED

Bachelor’s degree preferred or equivalent experience

Tools

MS Office

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a managerial professional to lead the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospitals, and ancillary facilities across the payment spectrum.

Responsibilities

• Lead or support the development and execution of network contracting strategy, including adoption of value‑based contracting for fee‑for‑service providers.
• Negotiate and manage contracts in accordance with Horizon reimbursement standards and key controls.
• Assist and implement provider contracting policies and procedures consistent with industry best practices and regulatory requirements.
• Ensure accurate implementation of contracts, maintain contract language and templates, and interface with matrix partners for network implementation.
• Coordinate across departments to report provider file maintenance requests, claims stops, and new hospital implementation.
• Adjudicate technical inefficiencies related to system‑wide claims, configuration, and provider mapping discrepancies.
• Conduct research, root‑cause analysis, and effectiveness reports to address operational deficiencies and improve efficiency.
• Implement industry initiatives and programs to achieve multi‑million dollar medical cost savings.
• Maintain provider catalog data, credentialing, recredentialing processes, and regulatory standards compliance.
• Provide leadership, training, goal setting, performance reviews, and salary administration for contracting staff.
• Represent the organization at industry conferences, webinars, and other events.

Qualifications & Education

• High School Diploma/GED required; Bachelor’s degree preferred or equivalent experience.
• Minimum 5 years of business experience in hospital and provider group finance and/or managed care network development.
• Minimum 5 years of knowledge and experience with contract finance and reimbursement methodologies (FFS, Medicare DRG/APC, Medicaid pricing, capitation, full risk, shared savings, incentive arrangements).
• Minimum 5 years of experience leading cross‑functional teams to achieve improvements.
• Minimum 5 years of provider experience in Commercial, Medicare, Medicaid, and Value‑Based programs.
• Minimum 3 years of health care cost data analysis and technical document writing.
• Minimum 3 years of supervisory experience and/or leading people by influence.

Skills & Abilities

• Ability to create, develop, and maintain business relationships.
• Strong analytical, business case, and product design skills.
• Sound judgment and the ability to ask probing questions.
• Detail oriented with strong organizational and problem‑solving skills.
• Adaptability to multiple responsibilities across the organization.
• Effective verbal and written communication; ability to present information to various audiences.

Knowledge

• Proficient in Windows‑based environment, MS Office (Word, Excel, PowerPoint) and Internet applications.
• Knowledge of principles of health care contracting, the health care/insurance industry, and New Jersey provider communities.
• Knowledge of laws and regulations governing insurance, HMO, hospital and physician practice.
• Knowledge of quality measurement approaches for insurance, HMO, hospital, and physician practice.

Travel

Moderate travel up to 60% required.

Equal Opportunity Statement

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, disability, or 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.