Job Description :
This job provides the leadership and day-to-day direction to advance strategic initiatives with the provider relations field staff and provider network. The role leverages combined areas, process, and technology competencies to support strategic partner provider engagements; collaborates with various internal teams to develop healthcare delivery and reimbursement solutions that will deliver value to customers; acts as subject matter expert and trusted advisor in both Highmark and provider spaces; and works closely with Highmark and provider leadership teams to define/implement strategic direction. Has the primary overall relationship with all providers to achieve the Organization’s strategic initiatives. This job is responsible for providing leadership to the staff driving customer value through provider facing advisory in support of the Organization’s provider partnership models, relationships with key large and complex providers, and other strategic initiatives. Accountabilities include, but are not limited to, playing key leadership role in provider partnerships, leading major engagements, contributing to strategic planning and leading execution, building key provider relationships, building and sharing institutional knowledge, effectively and proactively orchestrating conflict resolution /issue resolution in a matrix environment.
Essential Job Functions:
- Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
- Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
- In collaboration with the contracting team, identify and cultivate relationships with strategic partners and large/complex providers. Establish key contacts in all critical areas of the provider entity/system including clinical quality, revenue management, finance, utilization management, and C-suite.
- Identifies, develops grows partnership and key provider relationships implementing strategic initiatives jointly agreed upon, leading pilots and collaborations that will form the glide path for future transformation in care delivery and reimbursement models. This requires interfacing with various departments in the organization as well as vendor teams. Utilize data to make informed decisions, negotiation skills to achieve desired results, and project management skills to ensure successful execution of commitments. Working collaboratively across the enterprise, establishes networks to support strategic provider partnerships and products.
- In collaboration with the provider innovation team, drives the high level interactions and direction of the Pay for Value (P4V) relationships. Communicate with the leadership and appropriate business executives on the P4V program participation, opportunity, performance, and progress. Engage appropriate resources, tools, analytics, and reports to enable success in the programs to drive better health outcomes, lower unit costs, and higher patient satisfaction for our members.
- Conducts analysis and make data driven decisions to ensure we are getting appropriate returns on investments for initiatives, increasing quality, lowering cost, and increasing patient satisfaction. Work with actuary and informatics teams to develop population health tools/reports, care alignment reports, and other resources that will produce value for Highmark, the provider partner, and the member.
- Actively participates in the planning and development of the corporate provider network and contracting strategies that will deliver value to our customers including but not limited to: care delivery models (medical home, oncology, cardiology, orthopedics), alternative reimbursement models (bundle payment, shared savings, global payments), care management pilots and network optimization. Coordinates reimbursement model and STARS related programs at the provider level for all government programs products ACA (Medicare/Medicaid).
- Oversees administration of critical and timely communication to providers through ongoing personal contacts, site visits, regional communication sessions, meetings with professional organizations to communicate initiatives and changes.
- Develop, participate in, and support education to providers due to changing reimbursement environment, product portfolio, processing requirements, and new technology offerings.
- Other duties as assigned or requested.
- 7-10 plus years’ relevant industry experience (insurance, healthcare, hospital, etc.)
- 5 – 7 years’ provider relations and/or provider contracting experience
- 3 – 5 years’ program/project management experience
- 10 -15 years’ relevant industry experience (insurance, healthcare, hospital, etc.)
- Provider delivery experience (i.e. running a physician practice, working in hospital finance department, etc.
KNOWLEDGE, SKILLS & ABILITIES
- In depth understanding of the provider community – “market knowledge”
- Knowledge of reimbursement methodologies and model
- Global understanding of care delivery models
- Global understanding of the insurance industry
- Managerial experience ( leading teams)
- Oral and written communication skills
- Project management /processes / tools
- Strategic planning
TRAVEL REQUIREMENT: 25%
Employee Referral: Level 2
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