Hm Home And Community Svcs Llc
Job Description :
This job is a key member of the HCS Network Strategy and Reimbursement team, taking on a significant role for complex operational aspects of network design/development and value-based reimbursement programs. This includes evaluating networks and contract structures relative to current and proposed future state through the lens of the overall HCS post-acute network strategy, and making recommendations based on an understanding of that strategy. The incumbent will also support HCS as a subject matter expert on contract terms, including payment provisions, and develop recommendations for how to standardize these provisions and terms to best practice, value-based arrangements across multiple business lines, including Commercial, Medicare and Medicaid Programs. In addition, this role will be responsible for taking a significant operational/implementation role in the development of high performing networks that meet all geo access and capacity requirements, as well as the implementation and program management of value-based payment arrangements. The bulk of these activities will be accomplished through partnership with the Contract Strategy and Reimbursement Consultant. This role will work across the matrix to partner with key functions, including contract administration, provider contracting, legal, compliance, provider audit, and other key implementation stakeholders, and support multiple health plan clients and health plan providers.
Employee Referral Payout: Level 1
- Source and act as subject matter expert (SME) on post-acute provider contracts across all client markets and geographies. Understand payment and other contractual provisions and how those align to the HCS network and reimbursement strategy and roadmap. Make recommendations on evolution of these aspects aligned to the strategic roadmap.
- Survey provider landscape across geographies, including direct research and geo access/capacity modeling, to understand where network development may be needed and take a lead role for communication and development activities, including economic and rate modeling as needed.
- Work with key administrative and contracting personnel to make updates to contracts as needed across multiple clients and base contracts, including to support the annual network design cycle, and ensure providers receive appropriate notifications.
- Serve as liaison to HCS Network Performance team as SME for complex operational inquires and interact with providers to share knowledge, answer questions or obtain needed documents and insights when requested.
- Develop an understanding of the differences among contracts between multiple clients and geographies and make recommendations for standardization across markets and clients where possible.
- Work cross-functionally to play a lead facilitator role in implementation of pay-for-value programs and process and operational evolution of those programs.
- Maintain lists of provider participants in pay-for-value programs, and provider contact information, as well as records for auditing purposes. Support program operations such as requests for payments to providers.
- Work across the matrix to support provider change of ownership processing and make/track updates to provider repositories (i.e. CPR, Salesforce, eDelivery).
- Other duties as assigned or requested.
- Bachelor's Degree in Business, Finance, Information Management, Healthcare Administration or Health Related Discipline or 6 years of relevant and progressive experience in lieu of Bachelor's Degree
- 5 years in Health Care Administration, Contract Management, Network Development, Finance or a related field to include 5 years in Business Analysis, Economic Modeling or a related field
- Medicaid experience
- Health plan experience
- Skilled Nursing Facility experience
- SNF billing to include Medicaid
- Provider Reimbursement
- Microsoft Word, Excel and PowerPoint
- Outstanding Interpersonal Communication Skills
- Oral & Written Communication Skills
- Teamwork and Collaboration
- Business Analysis
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
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
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.
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