Company :Highmark Health
Job Description :
This job is directly responsible for outcomes of providers contracted in the Organization's gain/risk share arrangements and is a highly skilled expert in practice transformation to achieve the specific targets set in the individual gain/risk share contracts and is strategically focused on those data gaps that will result in the greatest ROI for the Organization. Further, in a matrix management environment, will be responsible for 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.
- Directly responsible for supporting providers contracted in the Organization's gain/risk share programs, with a goal of maximizing quality and ROI for the Organization. This includes analyzing 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
- Participates in the development and presentation of instructional materials for internal and external audiences.
- Provides feedback to and collaborates with the analytics team to ensure reports are accurate, and provide meaningful, actionable data. Provide assistance to providers 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.
- Bachelor's Degree in Business, Finance or Healthcare related field and an RN license
- Bachelor’s Degree in Nursing
- Master's Degree in Business, Finance, or Healthcare related field (can be clinical)
- 5 years in practice transformation including population health, ambulatory care setting quality and efficiency metrics, accountable care organization development and support, patient centered medical home, and electronic health records.
- Experience may be from either health plan or provider employers.
- Familiarity with electronic health records and population health IT solutions
- Demonstrated experience working with health care data and analytics
- Experience in Lean, Six Sigma, risk management, contract management, finance management
- Must be able to effectively resolve issues and problems across all areas of the corporation, by understanding corporate strategies, policy and scope of authority
- Because of the broad impact of decisions that are made, must be knowledgeable and sensitive to many internal and external corporate issues
- Aptitude for a high visibility position demanding integrity, uncompromising professionalism, diplomacy and conflict management
- Demonstrates a deep understanding of primary care practice operations and workflow across the continuum of variability in primary care and experience in managing provider and administrative leadership relationships
- Superior written and verbal communication skills and listening skills
- Ability to adapt engagement strategies to meet market needs
- Registered Nurse
Language (Other than English):
25% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
WFA - Work From Anywhere Pennsylvania Area - 100% Remote
** Due to overnight travel, candidate needs to reside between the North Eastern, PA and the Harrisburg area and including the Philadelphia area **
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
Referral Level: 1
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.
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