This position is responsible for proposing, maintaining and valuing pricing methodology and price levels such that the professional and ancillary provider networks are “right priced”, and incentives are created for providers to change/maintain behaviors that support health plan strategies and goals. This position keeps management apprised of issues and status, identifies opportunities for improvement, facilitates peer review activities, facilitates problem solving sessions, acts as a catalyst for change and constantly seeks opportunities to improve team functioning.

Due to the nature of this role, incumbents must be vaccinated for Covid-19.

Essential Responsibilities/Accountabilities:

• Develops and proposes alternative pricing methodologies and rate levels for physicians and ancillary service providers.
• Analyzes needs for the physician and ancillary networks.
• Reviews NYS deficiency reports to determine network needs
• Works collaboratively with sales to determine group/member network needs
• Develops alternative tiers and levels to create incentives and to channel care to appropriate settings.
• Identifies opportunities for reducing benefit expense.
• Identifies ways to work with providers more effectively and efficiently by simplifying pricing rules and variation.
• Accountable for price management functions for all products and will liaise with Utilization Management and Medical Affairs to ensure appropriate strategies are developed and implemented relative to benefit expense management.
• Accountable for valuation of fee schedule changes and staying within approved budgets.
• Works collaboratively with finance and actuarial to ensure any changes to rates/methodologies are appropriately accounted for.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Minimum Qualifications:

• Bachelors degree in Finance, Business, Economics or Actuarial Science required. Masters degree or Actuarial certification preferred.
• Must have experience in finance, actuarial, and/or negotiations.
• Must have at least five years experience in health care reimbursement.
• Must have excellent communication skills.
• Must be able to work constructively with external contacts including hospital administrators, owners of provider companies, physicians, provider organization leaders, and other providers of health and health related services and equipment.
• Must have a current and thorough understanding of healthcare, financial models, physician organizations, contracts, and the Corporations’ products, and must be able to effectively discuss these issues with others.
• Demonstrated awareness of medical and quality initiatives and the impact to pricing methodologies and rates required.
• Awareness of Blue Cross Association activities and knowledgeable about other Blue Plan pricing strategies, preferred.
• Must be knowledgeable of CMS pricing methodologies, NYS methodologies and industry best practice.
• Due to the nature of this role, incumbents must be vaccinated for Covid-19.

Physical Requirements:

Environment/workstation

• Ability to work prolonged periods sitting at a workstation and working on a computer.
• Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
• Typical office environment including fluorescent lighting.
• Ability to work in a home office for continuous periods of time for business continuity.

Travel

• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.

Lifting/handling

• Ability to lift, carry, push or pull 15 pounds or less.

Other Motions

• Manual dexterity including fine finger motion required.
• Repetitive motion required.

• Reaching, crouching, stooping, kneeling required.

Additional Requirements on current JDs

• Must have a valid Class D license and ability to operate a motor vehicle.

• The ability to hear, understand and speak clearly while using a phone, with or without a headset.

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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer