Company :
Highmark Inc.Job Description :
JOB SUMMARY
This position is responsible for creating plans and managing activities in support of governmental products where risk adjustment methodologies apply. Directs the daily activities of direct reports supporting risk adjustment programs and activities. Assesses viability of current direction/projects/operations and recommends strategies and tactics to satisfy current and future business needs. Actively seeks and identifies opportunities for improvement. Implements strategic and tactical improvements to the risk adjustment program and processes. Contributes to the establishment of strategic direction on the risk adjustment program. Manage information that will ensure accurate revenue projections.
ESSENTIAL RESPONSIBILITIES
- Contribute to the department’s strategic planning efforts by identifying both strategic and tactical opportunities for improvement and recommending solutions.
- Provide day-to-day managerial oversight for staff responsible for risk adjustment programs and activities. Ensure continuous improvement of processes and delivery of results within assigned area. Encourage innovation and focus resources, including staff not under direct managerial control, to ensure successful delivery of desired results. Optimizes the use of resources in assigned area using proven resource management techniques.
- Assess the impact of potential or actual regulatory changes impacting the assigned area. Ensure ongoing compliance in all activities within the assigned area.
- Oversee development and execution of processes that will support the capture of complete and accurate diagnosis coding. Work closely with management from other areas to ensure that appropriate processes are in place to increase data accuracy.
- Accountable to deliver on initiatives requiring cross-functional, matrix relationships. These initiatives may involve staff in different departments or business units within the organization, or vendors and/or strategic business partners.
- Identify risk associated with inaccurate coding and risk scores which could result in lost revenue, disadvantages relative to competitors and potential CMS sanctions or penalties and work with management to mitigate this risk.
- Participate in the identification, evaluation, and management of risk adjustment-related vendors, with an annual vendor spend that is over $35M that generates revenue in excess of $100M. Assist with the preparation of RFPs, evaluation of responses, selection of vendors, and execution of pilot programs or proof-of-concept efforts.
- Oversee the creation of presentations, reports, and documentation; collaborate and negotiate with departments who are stakeholders in or dependencies of the risk adjustment processes.
- Partner with PMO, stakeholders, IT, and others to deliver and maintain the infrastructure needed to support the risk adjustment processes, as well as analytics for both Stars and revenue management.
- Other duties as assigned or requested.
QUALIFICATIONS
Minimum
- Bachelor’s degree in Business or Health Administration, Statistics, Finance, Information Technology, or related field
- 3-5 years in a health insurance field
- 3-5 years mentoring others
Preferred
- Prior management experience
- Extensive knowledge of health insurance and/or provider operations
- 2 years of developing strategic and tactical solutions to diverse and complex business problems
- 2 years developing, communicating, and presenting concepts to varying audiences
- 3 years of using project management techniques
SKILLS
- The ability to manage multiple projects and successfully manage projects with internal areas and external clients is required.
- Strong oral, written, presentation, and negotiation skills as well as analytical and conceptual skills are required.
- The ability to comfortably and professionally interact with all levels of management and varied skillsets.
- Knowledge of query tools and financial analysis tools is preferred.
- Experience managing a diverse professional staff is also required.
- Must be able to take charge of and be accountable for management of staff working on multiple projects to ensure corporate deadlines and objectives are met. Ability to motivate high performance, multi-disciplinary teams. Demonstrated abilities in relationship management
- Respond to feedback and champion process improvement initiatives within assigned area
- Strong leadership, coaching, mentoring abilities that will develop/maintain a high-performing team
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.
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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