JOB SUMMARY
This job is the primary liaison to support identified providers in the market. The incumbent plays an active role in provider training and monitoring as well as enforcement of company policies and procedures while increasing provider efficiencies, performance, and maximizing quality (STAR/HEDIS). Responsible for reporting packages, support, escalated service, education on vendor delivered solutions and services, population health capabilities and resources, and alternative reimbursement model. The incumbent will interact with providers by telephone, email, and at times in person. They will be the primary point of contact for certain providers and are therefore responsible for facilitating inquiries. This means coordinating the troubleshooting and resolving provider complaints and ensuring that responses to inquiries are completed in a timely manner and according to established service and quality standards. This job interacts with matrixed areas of the organization, the market facing provider teams and external provider partners. The incumbent will function as a liaison with the providers and internal areas to support and manage the execution of the value-based reimbursement (VBR) programs for the organization. To be successful, the incumbent builds relationships with and work across many departments in the Health Plan.
ESSENTIAL RESPONSIBILITIES
Value-Based Reimbursement Support
Manage relationship with select providers to proactively measure, anticipate and prevent problems and achieve corporate objectives around VBR programs and strategic initiatives with providers. Assume the non-clinical lead role in the VBR performance and education for all assigned providers. Educate providers on changes to VBR programs, reporting and performance requirements, and new offerings. Meet with contacts at various levels at key physician practices to ensure appropriate levels of communication. Responsible for educating providers on initiatives focused on managing medical expense and maximizing HEDIS and STAR metrics in collaboration with internal resources.General Provider Support
Ensure critical and timely communication to providers regarding Highmark’s programs, initiatives, and provider’s performance through ongoing personal contacts. Follow up on issue resolution. Recommend process efficiencies, strategies for improvement, and/or solutions to align technology with business strategies.
Internal Partnership
Engage appropriate internal 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. Coordinate in a matrixed liaison role with contracting, operations, and support areas to ensure the appropriate development and execution of initiatives, communication needs, and issue resolution. Perform Provider Relations triage function; addresses issues raised by providers and routes communications to the appropriate area for handling. Maintain current market knowledge, industry knowledge and innovation awareness to drive the change needed to transform the way healthcare is delivered and reimbursed. Other duties as assigned or requested.EXPERIENCE
Required
5 years of experience in the healthcare/insurance industry 3 years of experience in presenting concepts to varying audiences 3 years of Project management experience or other relevant experience with high accountability for managing multiple tasks with defined deadlines
Preferred
SKILLS
Understanding of the provider community (market knowledge) and global understanding of care delivery models and the insurance industry. Ability to communicate effectively with providers and colleagues and articulate issues, problems, and solutions in a timely manner. Critical thinking skills. Knowledge of Highmark’s VBR programs, contract and performance requirements, and knowledge of reimbursement methodologies and models as well as financial and analytical modeling. Public speaking skills. Process/quality improvement and issue resolution skills. Strong written and oral communication and organizational/project management skills Broad knowledge and working experience with various software packages such as Microsoft PowerPoint, Excel, Word. Knowledge of required compliance with Centers of Medicaid and Medicare services (CMS) laws and regulations, policies and guidelines regarding Medicare Advantage and Medicaid plans; HIPAA privacy and security regulations.EDUCATION
Required
Bachelor’s degree in Business or Healthcare-related field or relevant experience and/or education as determined by the company in lieu of bachelor's degree.
Preferred
LICENSES or CERTIFICATIONS
Required
None
Preferred
Language (Other than English):
None
Travel Requirement:
Less than 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office- or Remote-based
Teaches / trains others
Occasionally
Travel from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Occasionally
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely
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, age, 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, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
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