Company :Highmark Inc.
Job Description :
Directs the development, implementation, oversight and continuous improvement of the systems, processes, policies and staffing necessary to ensure cost effective and consistent disease management, health coaching and case management services for a specific segment of Highmark’s members and/or specific health management products and services. Ensures attainment of client and/or market-specific operational, clinical and financial commitments and performance guarantees in addition to improved levels of member and provider satisfaction with the services. Participates as a key driver of the development and execution of corporate strategies for the effective delivery of proactive, innovative and engaging health coaching and case management services. Uses internal analyses and external benchmarking to remain market-competitive and to continuously enhance the services being offered to both group clients and individual members. Specific focus on helping members through the continuum of care in a high quality, effective and cost efficient manner while tracking and being responsible for outcomes. Ensures on-going development of managerial and professional staff.
- Directs the development, implementation, monitoring and continuous improvement of the systems, processes, policies and staffing to ensure effective disease management, health coaching and Case Management services for a specific segment of Highmark’s membership (e.g. national, regional, Medicare Advantage, FEP, special programs, etc.). Includes analysis and determination and reporting of the clinical and financial value of all member outreach.
- Ensures effective processes, including the use of predictive models, for the proactive identification, assessment and engagement of at-risk members in addition to those who are chronically ill.
- Collaborates with: 1) Market leaders, and sales to develop and implement solutions for emerging market and client needs including the requirements of CMS; 2) Physician staff in market segment and/or in the clinical function to ensure continuous improvements in the delivery and effectiveness of services and improvement in member outcomes.
- Develops staffing model with appropriate types of staff with relevant qualifications using a cost benefit model to demonstrate value (member clinical outcomes, care cost savings, etc.) relative to the cost of staff. Ensures staff meets productivity and efficiency and effectiveness metrics as well as other targets.
- Develops subordinates and enhances staff competencies through on-going education and assessments with a particular focus on motivational interviewing and engagement techniques in an environment that fosters employee growth and professionalism, the recruitment and retention of talented staff, staff education and development and performance planning and assessment.
- Uses benchmarking through scientific research, networking and literature searches to continuously raise the expectations of performance and remain competitive with the product offerings of other health plans and care management vendors.
- Develops and participates in strategic initiatives based on the business needs. Develops and manages the operational budget.
- Ensure that all staff are delivering services appropriate to meet member’s needs including social barriers and identification and removal of modifiable barrier that interfere with members attaining heath goals. Provide information on health care access, preventive and chronic scare interventions and screening and close all identified gaps in care (quality/STARS metrics). Work to assist members in receiving evidence –based care in the most suitable setting by appropriate providers.
- Oversees development and implementation of policies and procedures that meet the changing business needs while ensuring compliance with all applicable CMS, URAC, NCQA, FEP, DOH and DOI standards and regulations. Complete all required reporting per compliance requirements in professional and timely manner.
- Other duties as assigned or requested.
- Bachelor’s Degree in Nursing, Business Administration, Healthcare, Healthcare Administration, or Healthcare Management
- Master’s Degree in Nursing, Business Administration or Health Administration
- 10 years of health-related work experience which must
- 5 years in a management role
- 5 years leading a health-related (preferably utilization, case or disease management) function within a health related service
- 3 years with diverse populations and delivery models
LICENSES or CERTIFICATIONS
- Registered Nurse (RN)
- Certification by Case Management society of America or Disease Management certification.
- Excellent interpersonal and communication skills
- Strong leadership skills
- Strong commitment to continuous process improvement and effective change execution
- Strong analytic skills
- Results oriented
- Proven ability to effectively lead and develop department leaders and staff
- Demonstrate knowledge in Case Management and Disease Management and member engagement strategies
- Ability to work effectively as a team leader and team member and have a track record of developing and maintain positive relationships with all stakeholders
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 )
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