Company :Highmark Inc.
Job Description :
Researches, designs and develops new clinical programs while assuring effective delivery of Clinical Care and Wellness programs and initiatives. Supports enhancements and expansion of existing clinical programs, while ensuring market –specific operational, clinical and financial commitments and performance goals. The incumbent may lead a team to complete a design project, or may act as the representative for the clinical design team on a larger company wide initiative. Works side by side with the implementation team for smooth transitions to sustain the programs that were developed and works closely with internal and external stakeholders. Responsibilities include clinical literature review, competitive market research and clinical program design including development of interventions and outcome measures that support effective delivery of proactive, innovative and engaging case and condition management services. This includes ongoing performance evaluation to assure that programs are achieving the outcomes intended and making recommendations for enhancements and new development.
- Perform management responsibilities to include, but are 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.
- Develop and implement clinical programs, systems, and processes needed to ensure effective care management services for Case, Disease Management and Wellness programs for all lines of business.
- Direct and communicate with external contractors to support compliance and program/initiative roll-outs. This may include assisting in vetting vendors to fulfill specific program requirements or enhancements to program delivery.
- Facilitate the development of outcomes measurement and reporting, identification and stratification of members, and develop clinical tools for clinicians to deliver programs. Use performance measurement to continuously improve programs.
- Work closely with other departments to assess needs for new or enhanced programs, achieve company-wide and clinical department's specific initiatives. Maintain a working knowledge of project-related Medicare regulations to ensure the organization meets compliance standards; NCQA standards to ensure the organization meets accreditation standards; and Commercial account audits to ensure a constant state of audit readiness.
- Utilize literature review and research to design clinical programs that are best practice, utilize evidence-based best practice, meet regulatory requirements, and are consistent with triple aim initiatives or overall improvement to member or provider deliver systems.
- Conduct market research to identify healthcare trends that will raise the expectations of performance and maintain a competitive edge of product offered by other health plans and care management vendors.
- Collaborate/communicate with medical directors and other department managers to assure integration and coordination of new programs with the clinical areas, grievance, and quality improvement departments' ongoing programs and new initiatives.
- Develop and manage the updating of product documentation. Assist with the development of test plans and product testing.
- Partner effectively with Clinical Services Training to relay process changes, develop training content, and implement/deliver training effectively.
- Support the development of call quality tools and the performance of Inter Rater Reliability sessions across markets and teams to drive the identification and adoption of best practices in engagement, assessment and interventions that match expected program delivery and outcomes.
- Serve as the subject-matter expert for clinical responses to request for proposals (RFPs) to support growth and expansion. This may include: researching specific state programs, requirements related to the proposal, best practices in the proposed state or environment, as well as reading and interpreting RFP related draft agreements/contracts, preparing written responses, coordinating subject matter expert (SME) responses.
- Other duties as assigned.
- Bachelor's Degree
- 6 years of Clinical Nursing
Master's Degree in Business Administration, Business Management, Health Administration or Nursing
- 5 - 7 years developing clinical programs and providing oversight for on-going program evaluation
- 3 - 5 years in a Management role
- 3 - 5 years with Process Design
- 3 - 5 years in a Managed Care Environment
- 10 - 15 years in Healthcare
- 3 - 5 years in the Health Insurance Industry
- 3 - 5 years of Program/Project Management
- Experience in product testing or QA
LICENSES AND CERTIFICATIONS
Preferred (any of the following)
- Registered Nurse (RN)
- Six Sigma or Lean
- Creative Problem Solving
- Creative Thinking
- Project Management
- Business Analysis
- General Computer Skills
- Oral & Written Communication Skills
- Change Management
- Written & Oral Presentation Skills
- Function in a matrix environment
- Leading change
- Lean/Six Sigma
Language (other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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.
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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