Job Description :
JOB SUMMARY (Summarizes the major purpose and primary responsibilities)
This job is directly responsible for the value creation, impact and cost control and fiscal/ROI targets as set by the Organization, including revenue stream outcomes, and engagement of primary care providers (PCP) enrolled in government value based reimbursement programs and continuous improvement models. This job is a highly skilled subject matter expert (SME) in Medicare STARS, Medicaid HEDIS and risk revenue streams and provides strategic, hands-on, office based support to PCPs for analysis of performance Medicare STARS, Medicaid HEDIS and risk revenue streams, identifies opportunities for improvement in value creation, cost control and utilization, performance, and develops strategic plans in collaboration with PCPs and the inter-departmental teams for transformation of workflows resulting in outstanding performance in government program(s) ensuring that ROI targets set by the Organization are met or exceeded. Further, in a matrix management environment, the CTC is responsible for collaborative work with other functions in the provider area, data analytics, and key internal/external stake holders to provide the most appropriate support to the PCPs based upon data analysis and dashboard reports.
ESSENTIAL RESPONSIBILITIES (Describes the critical tasks, duties and responsibilities of the position.)
- Directly responsible to provide office based, hands-on assistance services (i.e. chart reviews, mass claims adjustments, UDC processes, etc.) to PCPs enrolled in Medicare STARS, Medicaid HEDIS and risk revenue programs and clinical evidence based guidelines. The CTC is expected to assess the needs of each individual PCP practice, and use a combination of on-site individual office based, entity level based, video conference, teleconference and electronic mail interactions to drive engagement and exemplary value creation, impact and cost control, and ROI/fiscal outcomes as set by the Organization for government programs.
- Directly responsible to analyze and interpret data in government value based reimbursement reports in the areas of Medicare STARS, Medicaid HEDIS and risk revenue and develop strategic plans to meet PCP government program targets to create value, impact and cost savings, as well as meeting the ROI as identified by the Organization.
- Directly responsible to assess data for highest ROI opportunities in PCP performance, and implement strategic plans to meet identified program targets across all of the Organization’s value based programs for both the commercial and government business (ACA, Medicare STARS, Medicaid HEDIS, risk revenue).
- Function as the Organization’s representative subject matter expert in government value based reimbursement programs and data analysis. This includes presentation of program results to both internal and external audiences, including practice and entity meetings.
- Participates in the development and presentation of instructional materials for internal and external audiences.
- Provide assistance to PCPs in the use of user interfaces, predicative analytic tools, and other population health management tools endorsed by Highmark.
- Independently and autonomously manage PCP caseloads, projects, meetings, deliverables, resources etc. for individualized strategic plans to transform PCP practices enrolled in government programs using innovative continuous improvement methodologies. This includes cross training in all of Highmark’s value based reimbursement programs to lend support as needed/defined by market outcomes.
- Serve as the clinical subject matter expert for PCP Medicare STARS, Medicaid HEDIS, and risk revenue programs for both internal and external Highmark key stake holders. In a matrix management environment, works collaboratively with the interdepartmental team to provide the most comprehensive support to PCPs for exemplary scores in government programs.
- Other duties as assigned or requested.
Bachelor’s Degree- Clinical or healthcare industry discipline
Substitutions (Acceptable substitutions in lieu of a degree 1 ½ years’ experience = 1 year college)
Clinical or healthcare industry discipline
Minimum: This section refers to the minimum years and type of applicable experience needed to perform the job. Minimum requirements must be non-comparative, objective, and relevant.
- 5-7 years’ of work experience in Medicare/Medicaid and risk revenue, primary care and the ambulatory care environment, healthcare insurance industry government programs, healthcare administration in primary care, or healthcare consulting in government programs for primary care
- 3 years’ experience in data analysis, interpretation, and outcomes strategic plan development
- Experience with Medicare STARS, Medicaid HEDIS, risk revenue value streams, and population health management
Preferred: This section refers to additional desired years and type of experience that the hiring manager would prefer, above and beyond the basic requirements of the job.
- 7-10 years’ of experience in a government program setting, managed care, primary care management or other clinical setting
- Experience in Lean, Six Sigma, TQI, TQC or other quality management certification
- Experience in health plan provider network performance management, population health management, continuous improvement or provider engagement models
KNOWLEDGE, SKILLS & ABILITIES (List the attributes required to perform the job through demonstrated service, education or training)
- 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
REQUIRED LICENSURE (Licenses that are required to perform the job)
TRAVEL REQUIREMENT: 50% – 75%
(List % of time traveling)
LANGUAGE REQUIREMENT (other than English)?
(List primary language)
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
(The physical, mental demands and working conditions described here are representative of those that must be met by an employee to successfully perform the essential function of their job. Reasonable accommodations will be made when necessary to enable individuals with disabilities to perform the essential duties of the position, to the extent that they do not cause undue hardship.
An employee in this position works in an office environment. The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email). The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks. The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.
Teaches/Trains others regularly Constantly
Travels regularly from the office to various work sites or from site-to-site Frequently
Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply
Physical Work Site Required No
Most On-The-Road Positions
An employee in this position may work in a home or company office environment but is also frequently driving to and from various locations to perform the work off-site. The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email). The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks. The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.
An employee in this position is frequently required to move throughout the workplace, sit, stand and walk, use hands and fingers to hold objects, tools or controls, possess fine motor skills (e.g., to write and operate a computer or to steer transportation equipment), possess gross motor skills (e.g., to carry items), reach with hands and arms, climb stairs and ladders, balance, stoop, kneel crouch and crawl, communicate effectively, and talk and hear. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. The employee must be able to work in a busy environment where decisions often must be made quickly, must attend work on a regular and reliable basis, must adhere to all workplace policies, and may be called upon to work outside regular business hours. This work occurs in a [example: warehouse, hospital or provider’s office or mailroom].
Lifting: up to 10 pounds Rarely
Lifting: 10 to 25 pounds Rarely
Lifting: 25 to 50 pounds Rarely
Changes Approved By:
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
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