Job Description :
This job is accountable for the ongoing operations and performance of the Organization’s provider programming strategy surrounding value based reimbursement (incorporating insight in support of enterprise product, IFDS integration and high performance network strategies) tor all regions and provider types (PCPs, specialists, facilities and health systems). Works closely with matrixed colleagues within the broader function and others across the health plan, the position will manage a portfolio of discrete value based reimbursement programs, track performance against metric and overall program goals, field requests from providers and ensure operations continue seamlessly. Once programs are launched, the incumbent prospectively and retrospectively reviews their clinical and cost-related results, and recommend/implement any changes that are needed to keep the programs viable.
- Perform management responsibilities including , but 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.
- Manage ongoing program management of reimbursement models in flight for PCPs, specialists, facilities and health systems, including monitoring overall program (ROI) and metric performance, making recommendations for when to retire or replace metrics that have “topped out” or providers are not responding to, working closely with field-facing colleagues to interpret reports and prepare for provider meetings and reporting out to the enterprise on overall provider performance and trends in the market.
- Assist in the development of recommendations for a broad range of business, clinical, and analytical technical capabilities. This position will be required to conduct discrete program analyses and reporting, identifying target audiences (both internal & external) to summarize and translate operational results for enterprise-wide value based programming into understandable results and trends.
- Field and develop or coordinate responses to program inquiries which may be sourced from both internal and external stakeholders.
- Direct operational execution of ongoing reimbursement programming updates. Manage the operations of the value based reimbursement programs adhering to specific reporting and resulting timelines, as well as demonstrating excellent project management skills with defined project milestones and dashboard reporting in compliance with required reporting standards while working other departments/functions across the organization.
- Review and assist colleagues with development of value based programming communication and educational materials.
- Complete department’s financial reporting and budgetary requirements (including, but not limited to, tracking division’s improving health care quality expenses for MLR reporting, operational cost savings) in line with corporate guidelines.
- Other duties as assigned or requested.
- Bachelor’s Degree in Healthcare, Business (Finance, Economics, Accounting)
- Master’s Degree in Healthcare, Business (Finance, Economics, Accounting)
- 3 – 5 years of experience in Healthcare, and/or Healthcare Insurance, Consulting, Administration or related areas
- 1 – 3 years of management experience
- Clinical knowledge is highly desirable, and ability to lead/manage highly trained clinical professional employees is critical.
LICENSES AND CERTIFICATIONS
- Certified Professional in Healthcare Quality (CPHQ)
- Working knowledge of physician practice management, hospital operations, comprehensive healthcare industry and finance/reimbursement knowledge
- Extensive knowledge of clinical quality metrics and measures
- Conflict management, leadership and mentoring acumen experience
- Expert problem solving aptitude and adaptability to a dynamic work environment
- Expert interpersonal and relationship management skills, presentation skills, facilitation and negotiation skills, communication skills
- Experience with process engineering, improvement and continuous quality improvement methodologies
- Expert data interpretation and analytical skills
- Lead, motivate and direct professional staff; demonstrate accomplishment in collaboration with mulit-disciplinary teams to achieve deliverables or outcomes within defined timelines.
LANGUAGE REQUIREMENT (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
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Physical work site required
Lifting: up to 10 pounds
Does Not Apply
Lifting: 10 to 25 pounds
Does Not Apply
Lifting: 25 to 50 pounds
Does Not Apply
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.
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.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice