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J195649

Provider Navigation Consultant

Highmark Health

  • Company Hignmark Health
  • Home, PA
  • Provider Services
  • Full time
  • Day (United States of America)

Company :

Highmark Health

Job Description : 

JOB SUMMARY

This job is directly responsible for the engagement of primary care and specialty providers (in and out of network) regarding their interactions and referral patterns with clients and members enrolled in the designated value and concierge-based programs assigned. The incumbent will support value creation, impact, cost control and fiscal/ROI targets for Well360 Clarity and other initiatives set by the organization. Will serve as a highly-skilled subject matter expert (SME) in the organization's Well360 Clarity and specialty programs. The incumbent will provide strategic, hands-on and/or virtual support for analysis of specialist performance in quality, cost and utilization. Will identify opportunities for value creation and develop strategic plans in collaboration with the providers and their inter-departmental teams for transformation of workflows related to specialist referrals utilizing Well 360 Clarity resources and tools. Will be responsible for collaborating with multiple stakeholders and will be responsible for improving cost outcomes, specialist referrals and quality. In the matrix environment, this job is responsible for collaborative work with other functions internally within the provider area, data analytics, and key internal/external stake holders to provide the most appropriate support to the client and providers based upon data analysis and dashboard reports.  Will be the liaison between the Strategic Integration (SI) team and Well360 Clarity team or other programs.


ESSENTIAL RESPONSIBILITIES

  • Directly responsible to provide a consultative, navigation, transformation workflow to facilities, primary care and specialist providers regarding members enrolled in the Well 360 Clarity (W3C) product.  Consult with primary care providers regarding a member's need for a Specialist and offer the support of the Well360 Clarity team for program interventions. Document all outcomes in the applicable systems. 
  • The role will collaborate with the Well360 Clarity team during huddles, staff meetings, and ongoing trainings to provide perspective on member-specific issues and needs.  Collaborate and coordinate efforts with Provider Relations (PAL) and the Strategic Integration department CTC's (TP, QBH, SPI) regarding member/provider-specific issues and needs on an as-needed basis.  
  • Provide training and education to the internal Highmark matrix partners as well as external facilities, primary care and specialty providers.  Education and training will included but not limited to:  Identify W3C members and how to identify them on the attribution report, the value of W3C and what it offers its members around care and support, and how to align members with high quality, cost efficient providers by utilizing the Value Based Reimbursement Program reports (True Performance, Speciliast Performance, etc.). 
  • Other duties as assigned or requested.


EDUCATION


Required

  • Bachelor's Degree in a Clinical or Healthcare related field


Substitutions

  • None


Preferred

  • Master's Degree in a Clinical or Healthcare related field


EXPERIENCE


Required

  • 5 years in a Healthcare, Quality Improvement programs, Medical Staff management, Healthcare (facility, primary care or specialty care) administration role OR  in Healthcare Consulting OR  in the Health Insurance Industry
  • 5 years in an Ambulatory Care Environment, including:
    • 3 years in Data Analysis/Interpretation/Outcome Strategic Plan Development OR  Value Based Reimbursement programs/Risk Revenue Value Streams/Population Health Management


Preferred

  • None

LICENSES or CERTIFICATIONS


Required

  • None


Preferred

  • None


SKILLS

  • Leading Change Management
  • Analytical and Logical Reasoning/Thinking Skills
  • Call Center Management/Analysis
  • Customer Service Oriented
  • Possess a Clinical Perspective
  • Business Process Improvement
  • Written & Oral Presentation Skills
  • Influence and Persuasion
  • Resource Management
  • Results Oriented


Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Frequently

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

Occasionally

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.

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

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice


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