Company :Highmark HealthJob Description : 

JOB SUMMARY

This job works closely with the management, and assists in developing new reimbursement models across the Organization's markets and business lines. This would include creating a comprehensive suite of reimbursement models that aligns the strategic objectives across multiple areas within provider organization and at AHN; defining new themes for reimbursement innovation, based on a deep understanding of innovation and trends in reimbursement from across the country, with a particular eye on options for responding to changes in both commercial and government reimbursement, including those CMS programs focused on provider innovation; developing a shared capability and implementation roadmap that is consistent across areas; consistently updating and infusing the Organization's reimbursement strategy with innovative approaches to achieve return on investment (ROI) and provider alignment; working with actuary, finance, and reimbursement operations to build the ROI frameworks of new programs.

ESSENTIAL RESPONSIBILITIES

Assist in development of the overall conceptualization, strategy alignment, and high-level design of new value-based reimbursement models for PCPs, specialists, and health systems across the Organization's footprint, based on deep understanding and knowledge of trends in other areas of the country with both government and private payers.  Programs will include but not be limited to pay-for-value programs, 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.Keep abreast of new developments in both the public and private reimbursement space, including new innovative models developed by CMS to ensure seamless integration and that the organization is ahead of the curve with regard to our strategy.  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.Work closely with colleagues at AHN and the Organization, support in the development of AHN specific reimbursement models as part of our strategy and as a means to pilot new programs.  Serve as a resource for the enterprise on issues related to value-based reimbursement, including impact to organizational strategic efforts or new programs in development at AHN.  Work closely with market leads and others across the enterprise to support the development of  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.Support strategic provider relationships to understand the current health care delivery state, readiness for change, test value based programming concepts and components, identify key partners, identify and proactively communicate market transformation concepts with provider and professional advocacy societies and key thought leaders.  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.Build collaborative relationships within the organization, external local, regional and national healthcare industry leadership to both inform market transformation strategies as well as to externally advance the organization's vision for care delivery transformation.  Relationships will include internal areas of the enterprise such as the strategic, financial, and clinical leadership of the enterprise, in addition to the multiple areas of health plan. External organizations by example include America's Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association Office of Clinical Affairs. Other duties as assigned or requested.

EDUCATION

Minimum

Bachelors Degree

Substitutions

None

Preferred

Masters Degree - MBA, MHA, MPH, MSc (Health Care Related)

EXPERIENCE

Minimum

5-7 years of experience in healthcare, and/or healthcare insurance, consulting, administration or related area2-3 years of experience in value-based reimbursement, through managed care contracting, provider reimbursement, consulting, population health delivery or related areas

Preferred

Experience who have clinical backgrounds and/or have worked as part of a health system or large physician organizationExperience in creating and implementing a value-based reimbursement model 

LICENSES AND CERTIFICATIONS

Required

None

Preferred

None

SKILLS

Excellent analytic and problem solving skillsExpert inter-personal and relationship management skills, presentation skills, facilitation and negotiation skills, communication skillsConflict management, leadership and mentoring acumen experience

Language Requirement (other than English)

None

Travel Required

0%- 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based 

General Description for Office-Based Positions

An employee in this position works in an office environment.  The position frequently requires the employee to communicate well with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Teaches / trains others regularly

Frequently

Travel regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (sales employees)

Does Not Apply

Physical work site required 

Yes

Lifting: up to 10 pounds

Frequently

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 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 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.

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. 

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