Job Details

Company :
Highmark Inc.Job Description :

JOB SUMMARY

This job manages the team that is responsible for the outcomes of providers contracted in the Organization's gain/risk share arrangements. This group is comprised of highly skilled experts in clinical workflow transformation. Their goal is to achieve specific targets set in the individual gain/risk share contracts, and they are strategically focused on those data gaps that will result in the greatest ROI for the Organization. Further, in a matrix management environment, the incumbent will be responsible for ensuring collaborative work with the other members of the value-based reimbursement team, provider relations, senior markets, analytics, actuary, and key internal/external stake holders to provide the most appropriate support for providers with gain/risk share contracts. The incumbent will be responsible for the overall clinical support needed to ensure entities success in new value-based reimbursement arrangements and will be expected to manage the needs of each entity in respect to population health data and analytics, strategic suggestions, and overall education on successful workflow adjustments to increase probability of success in futuristic value-based arrangements.

ESSENTIAL RESPONSIBILITIES

• Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
• Manage and develop the process of supporting providers contracted in the Organization's gain/risk share programs, with a goal of maximizing quality and ROI for the Organization. Responsible for their team reaching predetermined ROI targets for the given entities. Set goals and expectations around the use of performance reports and data to inform decision-making, process, and program implementation, as well as the development of process interventions based on practice-level data, trends and identified opportunities. Inclusive of, but not limited to: Advising primary care practices, physicians, nurses and other clinical staff to assist them on their conversion to value-based care; Dissemination and interpretation of quality and efficiency reports; When relevant, dissemination and support of gap closures for STARS and improved coding for government populations. Identification of process improvement gaps in workflow and development of individualized plans to remedy. Providing educational and training sessions. Creation and maintenance of relationships with specialists and/or hospital resources for providers employed in multi-specialty groups or health systems.
• For value-based contracts addressing government markets, directly responsible for the quality improvement and cost savings outcomes as a result of workflow transformation, superior coding accuracy, and Medicare STARS gap closure to providers based upon each individual gain/risk share contract parameters. This includes analysis and interpretation of claims submission for superior coding accuracy, cost and utilization reports, medical loss ratio reports, Medicare STARS gaps and other risk revenue opportunities.
• Function as the Organization's key contact on gain/risk share multi-disciplinary team. This includes presentation of program results to both internal and external audiences, including practice and entity meetings with the value-based reimbursement multi-disciplinary team.
• Develop overarching template and approach to presenting clinical support models that intertwine all stakeholders and maintain strategic direction of value-based contract. Participate in the development and presentation of instructional materials for internal and external audiences, educating others on the clinical support model designed for each entity.
• Provide feedback to and collaborate with the analytics team to manage templates to ensure reports are accurate, and provide meaningful, actionable data. Provide assistance to providers at the c-suite level, supporting the specialist, in the use of predictive analytic tools, user interfaces, population health management tools and other data-based platforms endorsed by the Organization.
• Independently and autonomously manage gain/risk share contract caseloads, projects, meetings, deliverables, resources etc. for individualized strategic plans to ensure significant cost savings for provider contract holders using innovative continuous improvement methodologies. This includes cross training in all of Organization's pay for value and value based reimbursement programs to lend support as needed/defined by market outcomes.
• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor's Degree in Business Administration/Management, Finance or Health Administration or relevant experience and/or education as determined by the company in lieu of bachelor's degree

Or

• High School Diploma with an RN License

Preferred

• Master's Degree in Business Administration/Management, Finance or Health Administration

EXPERIENCE

Required

• 5 years of Healthcare Industry experience
• 5 years of Operational Excellence experience
• 3 years of Management experience

Preferred

• 3 years of Data Analytics experience
• 3 years of Lean/Six Sigma experience
• 3 years of Contract Administration experience
• 1 years of Finance experience

LICENSES OR CERTIFICATIONS

Required

• None

Preferred

• Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

SKILLS

• Problem Solving & Decision Making
• Relationship-builder with Unsurpassed Interpersonal Skills
• Provider Management
• Operations Management
• Healthcare Information Technology

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:
$94,200.00

Pay Range Maximum:
$151,000.00

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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