Company :Highmark Health
Job Description :
This role manages design, implementation planning and execution of programs to improve appropriateness of care of Highmark’s members and patients. They will partner with lead clinicians and the Enterprise Care Analytics team to identify patterns of unwarranted variation in care. They will then work with internal partner teams within the enterprise to deliver programs at scale that will promote high-value care for all members. Initiatives could be composed of provider levers (e.g., peer-to-peer physician engagement), payor levers (e.g., medical / reimbursement policy) or blended levers (e.g., value-based reimbursement models).
- Partner with clinicians and analytics teams to identify patterns of unwarranted variation in care and design provider-led interventions to promote improved performance.
- Implement new clinical workflows or care models within the Allegheny Health Network and develop implementation plans to scale to other strategic providers.
- Work with internal partner functions across the enterprise (Medical Policy, Value-Based Reimbursement, Utilization Management, Payment Integrity) to scale impact by aligning policy and reimbursment with the latest evidence-based clinical guidelines.
- Develop holistic business cases that capture improvement to patient outcomes and total cost of care. Quantify impact as realized by different stakeholders, including patients, providers, employers and payors.
- Other duties as assigned or requested.
- Bachelor's degree in Health Sciences, Healthcare Admin, Business Administration or Nursing, PA, CNRP or six (6) years relevant and progressive experience in lieu
- 5 years healthcare administration experience in the provider domain
- 3 years progressive experience in area of specialization including leading large projects
- Master's degree in Health Sciences, Healthcare Admin, Business Administration
- 5 years experience with clinical patient care
- 3 years experience working directly with physicians
- 3 years experience developing business cases and building ROI for programs from planning to execution
- Thorough knowledge of payor medical and reimbursement policies, innovate reimbursement models
- Highly motivated with exceptional organizational skills, including the ability to effectively and competently handle multiple projects simultaneously and the flexibility and ability to quickly adapt to changes in work objectives
- Excellent written, interpersonal, communication, and presentation skills
- Managing through some levels of ambiguity. Ability to create a function “from scratch”
- Ability to effectively navigate matrix organizations and influence through relationships and shared purpose
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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
(Note– Include below for Highmark only – Not AHN or GH)
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.
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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
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