Company :
Highmark Inc.Job Description :
JOB SUMMARY
This job leads the overall performance of a Medicaid plan, for quality of care and service as well as financial performance. The incumbent delivers the revenue and operating gains for this market. They are accountable for establishing and maintaining strategic relationships within the assigned state, the care provider partners, key vendors, and the community at-large. The incumbent develops the strategic direction and insurers it’s execution for revenue management, federal and state regulatory and contract compliance, care management, and service to all key constituents through direct and indirect reporting relationships with the CMO, COO, CFO and Chief Compliance Officer as well as other key business partners. The incumbent provides strategic direction and management oversight of staff performing the core functions which are provided through administrative services agreement.
ESSENTIAL RESPONSIBILITIES
- 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
- Develop strategic goals and business plans to be executed at the health plan. Collaborate on the development and oversee implementation and reporting of the annual short- and long-term strategic business plan, budget, and financial projections to include all reporting required by local, state, and federal officials/ agencies.
- Work with Actuary, Finance, Executive Leadership and key business partners, lead the state contract RFP or rate renewal activities to ensure the acquisition, retention, and profitability of the business. Tasks include facilitating the proposal or rate renewal process, preparing rate proposals and related materials for executive leadership review/approval and for submission to the state, and serving as business lead in negotiations with the state.
- Develop and maintain mutually beneficial relationships with key elected officials, key community organizations and other influential local entities in support of the state's Medicaid programs and members as well as market and community goals. Stay current with federal and state health care reform, legislative and regulatory activities and proposed changes, assessing impacts, advising Highmark's public and private positions and engaging as needed to shape regulatory and contract outcomes.
- Develop and maintain positive, mutually beneficial relationships with strategic provider partners within the market. Partner with and provide both strategic and tactical direction to the provider network contracting team to build and enhance the provider network and related vendors to achieve the care, service and financial goals. As needed, engage in provider relations escalated service issues to achieve high provider satisfaction and deliver quality care to members.
- Work with Highmark Compliance, provide strategic direction and tactic guidance to the compliance programs and practices to ensure full compliance to federal/state regulations and contract terms and conditions. In coordination with Highmark Compliance, provide business leadership to all compliance reviews, such as ERQ and ISCA, as well as other external organizations such as BCBSA and NCQA.
- Lead and manage the team and organization to execute our care and service commitments to our key constituents with a primary focus on serving and caring for our members. Work to continuously improve the health plans performance, minimize performance risks, and engage in escalated issues to achieve mutually satisfactory outcomes, with a focus on membership care and satisfaction.
EDUCATION
Required
- Bachelor's Degree in Business Administration/Management
Substitutions
- None
Preferred
- Master's Degree in Government
EXPERIENCE
Required
- 10 years of Medicaid Experience
- 10 years in Management
Preferred
- None
LICENSES OR CERTIFICATIONS
Required
- None
Preferred
- None
SKILLS
- Financial Risk Management
- Government Programs
- Sales
- Communication Skills
- Presentation Delivery
- Business Strategy
- Collaboration
- Managed Care
Languages (other the English)
None
Travel Required
25% - 50%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office Based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Occasionally
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Rarely
Lifting: 10 to 25 pounds
Never
Lifting: 25 to 50 pounds
Never
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.
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 any category protected by applicable federal, state, or local law.
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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
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