Company :Highmark HealthJob Description : 

JOB SUMMARY

This position has direct responsibility for defining and executing the long-term strategic direction of the company through direct involvement in program design to transform the way that care is delivered, accessed, valued, and reimbursed across all three states that Highmark serves.  Approximately $20 billion in Highmark Health Services provider reimbursement, $1 billion in United Concordia Dental reimbursement and TBD in ASP/BPO partner reimbursement flow through this function annually across all of Highmark's diverse lines of business (Commercial, Medicare Advantage, and Medicaid) and the three unique states.  This position also serves as the reporting and analytical support for provider market contracting and relations, which includes management of the cross market unit cost process, key performance indicators as it relates to Highmark's competitive market position.  A combination of the competitive intelligence that comes from these functions drives the provider network design strategies this leader drives through the three states that Highmark services in close partnership with Product Development and the broader Sales organizations.  Included in these responsibility is all aspects of provider contract development, credentialing, demographics, and reimbursement management across all three states and lines of businesses for more than 85,000 practitioners and 220 facilities leading to the administration of over a 130,000 contracts.  This position is also responsible for coordinating payment models across all the Highmark entities that support the IDFS strategy, including AHN and Home and Community Services.  The leader also serves as Highmark's representative as the High Performing Network and Blue Distinction Total Care Executive  to the Blue Cross and Blue Shield Association.  Lastly this position is responsible for developing and maintaining executive relationships with ASP/BPO partner counterparts and for supporting the related process and system builds and implementations.

ESSENTIAL RESPONSIBILITIES

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.Pay for Value Program Design: Provide executive direction to lead the strategy to design new pay for value programs in partnership with Actuary, Advanced Analytics and Provider Markets.  This includes the assessment, design, develop programs and new capabilities, to reward providers for their role in transforming the cost and quality of care. Programs includes patient-centered medical home, accountable care alliance/organization and various specialist pay for value program. Based on program design and evolution, develop the appropriate strategy for associated reimbursement innovation. Ensure program ROI and adjust reimbursement as necessary.Innovative Reimbursement Models:  Provide strategic direction for the assessment, design, implementation and performance of new reimbursement models.  Ensure alignment with care delivery model transformation strategies and actuarial assumptions. Define evolution of reimbursement strategies to support financial viability of Highmark and partners, while driving towards a desired end-state payment model across the health care ecosystem.  Ensure that alternative payment models are industry-leading, highly relevant to the local market and support the desired clinical and operational models designed for care delivery transformation. Represent Highmark with the BCBSA and other Blues on Payment Innovation teams and other related forms. Charter, budget and sponsor and oversee cross-functional projects to implement the methods. Reimbursement models may include bundled payment arrangements, gain sharing arrangements, risk-reward financial arrangements, capitation, etc.Network Design: Provide executive direction to set the strategy for Network Designs within Highmark footprint and in partnership with BCBS Association.  This includes connecting with key with partners like product development and other stakeholders to design and build provider network models for all lines of business.  In scope for this role includes strategic direction on centers of excellence, and other creative designs that meet both local and national market requirements, and to enable membership growth strategies.  This will require procuring all the analytical support, and building out the key system capabilities to enable the networks to flow through all the adjudication functions and any member facing materials.Capitation Business Ownership: Serve as the end-to-end owner of the new capitation solution, including the pmpm payment process/system and the claims logic to pay FFS above capitation. Oversee the definition and prioritization of build and enhancement requests from ASP/BPO partners, Highmark regions and other to ensure that the solution evolves in a way that keeps it globally relevant. Build and maintain executive relationships with counterparts in our customer organizationsProvider Contract Development: Lead the strategic development of all provider contract content and administration for all the Highmark foot print.  This includes developing standards, streamlining business process and meeting regulatory compliance requirements.  These contracts will support all lines of business within all three states that Highmark participates.Reimbursement Governance: Provide executive direction and oversight for the short and long-term reimbursement strategy, method integrity and method evolution. Chair a cross-functional (Provider Markets, Medical Policy, Actuary, Provider Partnership Programs, Network Management, etc.) executive team to ensure cost of care performance of both fee for service reimbursement and the innovation reimbursement associated with pay for value programs. Work with peer groups (FIPR, Actuary, etc.) to identify possible anomalies or abuses of reimbursement and take policy, process and/or system steps to correct. Consider external (national consulting firms, actuarial firms or other) comparisons and analyses regarding method / fee schedule performance.  This position is also responsible for ensuring policy and process for the rate and fee schedule administration component of all reimbursement to maintain fiscal compliance with provider contracts and to mitigate risk under internal and external audit, Sarbanes Oxley, SAS 70, CMS compliance audits and Partner Plan arrangements.Institutional Reimbursement Methods:  Provide executive direction on the strategy, evolution, maintenance and decision support of all institutional payment methodologies including, but not limited to, DRG weight-based methods, APCs, fee schedules and other customized fee for service methods in support of provider contracts.  Ensure partnerships with provider markets (CPA, WPA, WV and DE) are fully functioning to deliver the highest performing provider reimbursement approach possible with every contracted provider. Oversee the evaluation of method performance and execute plans to fill gaps in cost of care performance through method retirement, code edit implementation, etc. Ensure defensibility and integrity of methods. Ensure audit performance through SSAE 16 and MAR certification.Professional Reimbursement and Code Governance:  Provide executive direction on the strategy, evolution, development, implementation and maintenance of state-wide professional fee schedules, as well as the implementation and maintenance of corporate tables and databases related to national coding structures (CPT, HCPCs, ICD-9/ICD-10 diagnosis, modifiers). Govern all fee schedule adjustments, special deals, etc. Align fee schedule and network strategies. Ensure audit performance through SSAE 16 and MAR certification.Provider Information Management:  Provide executive direction to this  strategic operational capability within the scope of this role.  This includes the ownership for the development and ongoing maintenance of all the core systems , business processes and other necessary functions to maintain all credentialing, demographic data, pricing information or any other attribute about associated with the management of Highmark's providers and corresponding networks.  The ownership of these functions are across all three states (PA, DE, WV) and includes the credentialing committee, NCQA standards, demographic data accuracy or any other regulatory and compliance requirement that is required to support the providers in Highmark's network.  There is close partnership with the Health Plan Operational business unit to make sure that all the provider attributes are used appropriately.Reimbursement & Provider Data Consulting for New Payer Partners:  As Highmark expands its ASP/BPO model and on-boards new payer customers, lead efforts to design, build and maintain the appropriate reimbursement consulting / training expertise and processes. Represent the reimbursement capabilities to potential and actual payer customers. Ensure that proprietary methodologies and rates are not exchanged.Technology Roadmap: Provide executive direction in leading the business strategy in developing capabilities that drive a people/process/technology perspective.  This includes having ownership of development of key capabilities that are necessary to execute across all of Highmark's provider Network strategy.  This impacts the systems that focus on:  provider pricing, value based reimbursement, payment policy, provider credentialing, provider demographics, contract management, bundle payment, managing all health care code sets, third party vender applications, analytical tools, and other third party applications that support provider network management.Other duties as assigned or requested.

EDUCATION

Required

Bachelor's Degree in Business, Finance, Healthcare administration or a related field.

Substitutions

Ten years of relevant work experience

Preferred

Master's in Business Administration or Healthcare Administration

EXPERIENCE

Required

10+ years of experience in healthcare, and/or healthcare insurance, consulting, administration or related area5+ years' of experience in value-based reimbursement, through managed care contracting, provider reimbursement, consulting, population health delivery or related areas

Strong financial background and analytical skills with a deep understanding of the economic drivers of healthcare 

Proven experience in working in a Health Economist capacity driving understanding of current health trends.

Extensive knowledge of new and emerging trends in reimbursement, network, and payment model design.  Demonstrate of the application of healthcare economic drivers and/or population health based analytics.

Experience working with technology vendors, and other service provider solutions to source key capabilities

Excellent written and oral communication skills with the ability to present complex information clearly and persuasively.  Including excellent leadership skills, with the ability to relate to all levels of management and staff as well as individuals external to the corporation

Demonstrate ability to work effectively and efficiently in a matrix organization structure mode

Demonstrated knowledge of with core health plan reimbursement and provider data operational functions

Preferred

Familiarity with alternative care model designs (e.g., patient centered medical home, ACO), alternative reimbursement models (e.g., bundled payments), and provider / health plan quality programs (e.g. pay for performance)Experience working in an Actuarial Science capacityFamiliarity with the delivery of health care services across the continuum and quality metrics.Experience in running large cross organizational programs.Comfort and with real-time calculations of cost, membership, etc. (i.e., “back of the envelope” estimations)Familiarity with health plan and provider contracting or revenue management Understanding of provider contract documents and overall contract management processClinical background and/or worked as part of a health system or large physician organization

LICENSES OR CERTIFICATIONS

Required

None

Preferred

None

SKILLS

Excellent leadership skills, with the ability to relate to all levels of management and staff as well as individuals external to the corporationHighly effective oral and written communications skillsAbility to manage multiple, complex projects within prescribed timelinesProficient in MS Office suite, including Word, Excel, PowerPoint and project management softwareHigh level of autonomy and self-direction, to guide reimbursement model design from concept through to executionAbility to successfully navigate complex organization, engaging multiple stakeholders to achieve reimbursement objectivesHigh level of autonomy and self-direction, to guide reimbursement model design from concept through to execution

Language (other than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Does Not Apply

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

Lifting: up to 10 pounds

Constantly

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.

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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