Job Description :
This job works closely with management and assists in developing new reimbursement models for the Organization's strategic partners and initiatives. The incumbent influences value-based payment integration into the overall enterprise strategy through collaboration with Senior-level internal/external stakeholders. The role will serve as a strategic advisor and partner to the organizations most critical provider partners. They will work to ensure the development, efficiency, and effectiveness of advanced value-based payment models, including customized development, VBR Design models. The job works closely with leadership and other stakeholders to develop, coordinate and manage analysis accompanying existing and new reimbursement models, as well as provide analysis in the development and support of VBR projects required to make effective business decisions and recommend innovative approaches to VBR models. Serves as a liaison among numerous internal customers, including but not limited to VBR team members, operations, actuary, and advanced analytics and reporting. There is a significant emphasis placed on frequent and meaningful interactions with business segment and functional department executive/senior leadership to ensure that new reimbursement initiatives and existing program improvements are deployed with our most advanced partners. This will require engagement with Health Plan Management (SVPs, VPs, Directors, etc.) and provider leadership (CFOs, CMOs, VPs, etc.) in formal and informal situations, and strong demonstration of analytical, communicative, and influencing skills.
- Support and lead the development and completion (from model conception to implementation) of value-based programs for key strategic accounts and/or initiatives
- Evolve strategic provider relationships to drive quadruple aim value across Highmark, the providers, members, and our customers current; test value-based programming concepts and components, identify and proactively communicate market transformation concepts with providers and internal stakeholders
- Deploy pay-for-value programs across episode payments, prospective bundled payments, gain share and risk share models and will be implemented for the organization's Medicare Advantage, Medicaid, ACA, and commercial populations with the goal of maximizing quality while reducing healthcare costs
- Ensure integration with enterprise strategic direction. Collaborate with stakeholders to incorporate VBR into product, network, and provider integration. Liaise with Enterprise & P&L leaders on their overarching strategies to ensure broader alignment of VBR approach.
- Develop targeted reimbursement models that support enterprise strategic initiatives that might fall outside of planned value-based reimbursement designs and/or to serve as a focus of innovation.
- Work with reimbursement, actuary, and analytic departments to ensure that operational capabilities are built in line with the strategic roadmap to ensure maximum flexibility and speed to market
- Serve as a subject matter expert working in concert with provider relations and clinical transformation consultants to explain new programs and results to key provider partners
- Provide superior ability to analyze and forecast effects and implementation of beneficial but complex financial arrangements with strategic partners
- Serve as a resource for the enterprise on issues related to value-based reimbursement, including impact to organizational strategic efforts and new programs in development
- Lead in a matrixed work environment.
- Help drive a culture change from “reporting the past” to “creating the solutions for future.”
- Other duties as assigned
• High School Diploma/GED
• Bachelor's Degree
• Bachelor's Degree in Actuarial Science, Mathematics, Economics or Health Administration
• Master's Degree
• 3 – 5 years in the Healthcare Industry
• 3 – 5 working on a Cross-Functional Project team
• 3 – 5 years in Data Analytics
• 1 – 3 years in Health Insurance Industry, Consulting, or Clinical Services
• Analysis of business problems/needs
• Analytical Skills
• Collaborative Problem Solving
• Creative Thinking
• Oral & Written Communication Skills
• Strategic Thinking
• Presentation Delivery
• Business Planning
• Financial Modeling
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
Works primarily out-of-the office selling products/services (sales employees)
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 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.
Referral Level Payout 2
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