Director Reimbursement Design & Market Evaluation

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Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job owns the strategic design and analytical approach to reimbursement. In order to be successful, the incumbent will work closely with stakeholders across the enterprise in the development and implementation of an integrated roadmap for the introduction and delivery of new and innovative reimbursement models across all of Highmark's markets and lines of business. This will require aligning new models to the health plan's strategic objectives based on a deep understanding of innovation and industry trends in both the commercial and government lines of business. This team will be responsible for developing and maintaining analytical models that will drive both the return on investment (ROI), and other decisions on the payer partnership constructs. These new approaches require new operational capabilities, and this team is responsible for identifying those gaps, building requirements to drive the development of new capabilities, and tying them to Highmark's strategic capability roadmap. If gaps are identified outside of their immediate scope, they will need to work effectively across teams to inform and influence change to drive adoption and close gaps. Critical partners include Advanced Analytics, Contracting and Provider Relations, Actuary, Finance, Highmark Health Solutions, Health Plan Operations.

ESSENTIAL RESPONSIBILITIES

• 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.
• Develop the overall conceptualization, strategy alignment, financial models, and high-level design of new reimbursement models for both government and private payers. Programs will include but not be limited to fee for service, pay-for-value programs, episode payments, prospective bundled payments, gain share and risk share models across all lines of business with the goal of maximizing quality while reducing healthcare costs. Develops and maintains a 3-5 year strategic roadmap outlining current and future reimbursement designs across markets and lines of business with input from key executives across the organization. It will require that this team keeps 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 in a Health Economist approach to build and maintain analytical models that performs evaluation of reimbursement models. Continuously evaluates models and seeks for innovative ways to make improvements based on data and market research. Working closely with Contracting and Provider Relation Leaders and others across the enterprise to develop 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.
• Develop and maintains 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.
• Other duties as assigned or requested.
  
  

EDUCATION

Required

• Bachelor's Degree in Business, Finance, Healthcare Administration, or Related Field
  
  

Substitutions

• 6 years of relevant work experience
  
  

Preferred

• Master's Degree in Business or Healthcare Administration
  
  

EXPERIENCE

Minimum

• 7 years Healthcare, Healthcare Insurance, Consulting or related area
• 3 years Value-based reimbursement, through managed care contracting, provider reimbursement, consulting, population health delivery or related areas
• 4 years Research and strategic planning around emerging trends in reimbursement, network, and payment model design. Demonstrate of the application of healthcare economic drivers and/or population health based analytics
  
  

To include

• 1 year Experience working with technology vendors, and other service provider solutions to source key capabilities
• 2 years Proven experience in working in a Health Economist capacity driving understanding of current health trends.
  
  

Preferred

• 5 years 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)
• 5 years Familiarity with the delivery of health care services across the continuum and quality metrics.
• 5 years Experience in running large cross organizational programs.
• 5 years Familiarity with health plan and provider contracting or revenue management
• 3 years Experience working in an Actuarial Science capacity
• 2 years Understanding of provider contract documents and overall contract management process
• 1 year Clinical background and/or worked as part of a health system or large physician organization
  
  

LICENSES or CERTIFICATIONS

Required

• None
  
  

Preferred

• None
  
  

SKILLS

• 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
• Highly effective oral and written communications skills
• Ability to manage multiple, complex projects within prescribed timelines
• Proficient in MS Office suite, including Word, Excel, PowerPoint and project management software
• High level of autonomy and self-direction, to guide reimbursement model design from concept through to execution
• Ability to successfully navigate complex organization, engaging multiple stakeholders to achieve reimbursement objectives
• Strong financial background and analytical skills with a deep understanding of the economic drivers of healthcare
• Comfort and with real-time calculations of cost, membership, etc. (i.e., “back of the envelope” estimations)
  
  

Language: (Other than English)

• None
  
  

Travel Requirement:

• 0% - 25%
  
  

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Frequently

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

Rarely

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

Does Not Apply

Physical work site required

Yes

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.

Pay Range Minimum:

$126,400.00

Pay Range Maximum:

$236,000.00

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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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Req ID: J260453