Company :

Job Description :

JOB SUMMARY

This role is accountable for any program or strategic tactic to drive provider performance in the domains of reimbursement and network programs. Specifically, the incumbent will lead the strategy and creation of value-based reimbursement (VBR) & risk programs, as well as the overall provider inventive and payment strategy. The role also leads the strategy and creation of provider network designs and programs.

The incumbent is responsible for understanding regulatory trends and competitive advantages / disadvantages when formulating strategies. Accountable in any program design for the full business case including implementation strategy and working with rest of organization to ensure resources, technology, communications, training are in place. Programs should be ready to operationalize once transitioned. The incumbent will develop market rollout plans and roadmaps for the programs and will tie in enterprise and provider strategy into the creation of these programs.

ESSENTIAL RESPONSIBILITIES

• Responsible for the strategy and creation of provider reimbursement programs to position the organization competitively based on market trends and forecasting.
• Lead the team that builds, updates, and maintains and the multi-year roadmap for reimbursement program evolution. This includes custom VBR programs established with strategic provider partners, joint economic models, and standard models such as True Performance and Quality Blue.
• Responsible for creating on a holistic incentive and payment strategy, including RPM, STARS, and Quality programs. Gain approval from internal stakeholders, and communicate the support and requirements needed across the enterprise to operationalize.
• Develop and maintain HPN network design strategy, translating product / segment needs to provider and market executives.
• Oversee development of tools and analytics needed for identification, inclusion, and management of network participants. Oversee design and development of Network performance scorecards.
• Responsible for ensuring alignment strategy and tactical playbook drives volume to preferred networks in each market, and responsible for working with market executive function to set steerage goals.
• Oversee strategy for disruption and mitigation planning.
• Perform 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. 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.
• Other duties as assigned or requested.

EXPERIENCE

Required

• 10 years of relevant experience in large, complex, highly matrixed organization
• 7 years leadership experience
• 7 years in Healthcare Strategy, with strong preference for Payor experience
• Extensive knowledge of new and emerging trends in reimbursement, network and payment model design or management.
• Understanding of regulatory trends in reimbursement (CMS, Price Transparency etc.)
• Excellent written and oral communication skills with the ability to present complex information clearly and persuasively.

Preferred

• None

EDUCATION

Required

• Bachelor’s degree in business, Healthcare administration or a related field required.

Substitutions

• None

Preferred

• Master's Degree.

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• None

Language (Other than English):

None

Travel Requirement:

0% - 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

No

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.

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