Highmark Health
Director Reimbursement Design & Market Evaluation
Highmark Health, Richmond, Virginia, United States, 23214
Overview
Company :
Highmark Inc. Job Description :
This position supports the matrixed strategic design and analytical approach to reimbursement. The incumbent will work closely with stakeholders across the enterprise to develop and implement an integrated roadmap for new and innovative reimbursement models across Highmark's markets and lines of business. The role requires aligning new models with the health plan's strategic objectives based on innovation and industry trends in both commercial and government lines of business. The team will support development and maintenance of models that drive ROI and other decisions on payer partnership constructs, identify operational gaps, build requirements to develop new capabilities, and tie them to Highmark's strategic capability roadmap. The role involves cross-team collaboration to inform and influence change to drive adoption and ROI realization. Key partners include Advanced Analytics, Contracting, Market and Provider Support, Actuary, Finance, Highmark Health Solutions, Health Plan Operations.
Essential Responsibilities
Perform management responsibilities including hiring and termination decisions, coaching and development, rewards and recognition, performance management, and staff productivity. Plan, organize, staff, direct and control day-to-day operations; develop and implement policies and programs; 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 include fee-for-service, pay-for-value, episode payments, prospective bundled payments, gain share and risk share models across lines of business. Develops and maintains a 3-5 year strategic roadmap outlining current and future reimbursement designs with input from key executives. Stay current with public and private reimbursement developments to ensure alignment with strategy.
Apply Health Economist concepts to build and maintain analytical models evaluating reimbursement models. Continuously evaluate models and seek improvements based on data and market research. Collaborate with Contracting and Provider Relations and other stakeholders to develop targeted reimbursement models supporting enterprise initiatives.
Develop and maintain strategic provider relationships to understand the current healthcare delivery state, readiness for change, test value-based programming concepts, identify partners, and communicate market transformation concepts with provider and professional advocacy groups. Serve as a subject matter expert working with provider relations and clinical transformation consultants to explain programs and results to 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 reimbursement, network, and payment model design; apply healthcare economic drivers and/or population health analytics
To include:
1 year experience with technology vendors and service providers to source capabilities
2 years experience 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 delivery of health care services across the continuum and quality metrics
5 years experience running large cross-organizational programs and projects
5 years familiarity with health plan and provider contracting or revenue management
2 years understanding provider contract documents and contract management
Licenses or Certifications
Required : None
Preferred : None
Skills
Excellent written and oral communication skills with the ability to present complex information clearly and persuasively. Strong leadership abilities to relate to all management levels and external stakeholders.
Effective oral and written communication skills
Ability to manage multiple, complex projects within prescribed timelines
Proficient in MS Office suite (Word, Excel, PowerPoint) and project management software
High level of autonomy to guide reimbursement model design from concept to execution
Ability to navigate a complex organization with multiple stakeholders to achieve reimbursement objectives
Strong financial background and analytical skills with understanding of healthcare economic drivers
Comfort with real-time calculations of cost, membership, etc. (budget estimates)
Language None
Travel
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 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
Compliance and Notices The job description outlines the general nature and essential duties and responsibilities of the role. It may not contain a comprehensive list of all duties, responsibilities, and qualifications.
This job adheres to ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. Employees may have access to confidential information and must comply with HIPAA and the company’s privacy and security policies.
Employees must comply with the company’s Code of Business Conduct, including applicable laws, regulations, policies, and training requirements.
Pay Pay Range Minimum: $126,400.00
Pay Range Maximum: $236,000.00
Base pay is determined by qualifications, experience, and other factors; the salary range may vary by location and market.
Highmark Health and its affiliates prohibit discrimination and strive for accessibility. For accommodation requests, contact HR Services Online at HRServices@highmarkhealth.org. Req ID: J267196
#J-18808-Ljbffr
Company :
Highmark Inc. Job Description :
This position supports the matrixed strategic design and analytical approach to reimbursement. The incumbent will work closely with stakeholders across the enterprise to develop and implement an integrated roadmap for new and innovative reimbursement models across Highmark's markets and lines of business. The role requires aligning new models with the health plan's strategic objectives based on innovation and industry trends in both commercial and government lines of business. The team will support development and maintenance of models that drive ROI and other decisions on payer partnership constructs, identify operational gaps, build requirements to develop new capabilities, and tie them to Highmark's strategic capability roadmap. The role involves cross-team collaboration to inform and influence change to drive adoption and ROI realization. Key partners include Advanced Analytics, Contracting, Market and Provider Support, Actuary, Finance, Highmark Health Solutions, Health Plan Operations.
Essential Responsibilities
Perform management responsibilities including hiring and termination decisions, coaching and development, rewards and recognition, performance management, and staff productivity. Plan, organize, staff, direct and control day-to-day operations; develop and implement policies and programs; 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 include fee-for-service, pay-for-value, episode payments, prospective bundled payments, gain share and risk share models across lines of business. Develops and maintains a 3-5 year strategic roadmap outlining current and future reimbursement designs with input from key executives. Stay current with public and private reimbursement developments to ensure alignment with strategy.
Apply Health Economist concepts to build and maintain analytical models evaluating reimbursement models. Continuously evaluate models and seek improvements based on data and market research. Collaborate with Contracting and Provider Relations and other stakeholders to develop targeted reimbursement models supporting enterprise initiatives.
Develop and maintain strategic provider relationships to understand the current healthcare delivery state, readiness for change, test value-based programming concepts, identify partners, and communicate market transformation concepts with provider and professional advocacy groups. Serve as a subject matter expert working with provider relations and clinical transformation consultants to explain programs and results to 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 reimbursement, network, and payment model design; apply healthcare economic drivers and/or population health analytics
To include:
1 year experience with technology vendors and service providers to source capabilities
2 years experience 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 delivery of health care services across the continuum and quality metrics
5 years experience running large cross-organizational programs and projects
5 years familiarity with health plan and provider contracting or revenue management
2 years understanding provider contract documents and contract management
Licenses or Certifications
Required : None
Preferred : None
Skills
Excellent written and oral communication skills with the ability to present complex information clearly and persuasively. Strong leadership abilities to relate to all management levels and external stakeholders.
Effective oral and written communication skills
Ability to manage multiple, complex projects within prescribed timelines
Proficient in MS Office suite (Word, Excel, PowerPoint) and project management software
High level of autonomy to guide reimbursement model design from concept to execution
Ability to navigate a complex organization with multiple stakeholders to achieve reimbursement objectives
Strong financial background and analytical skills with understanding of healthcare economic drivers
Comfort with real-time calculations of cost, membership, etc. (budget estimates)
Language None
Travel
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 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
Compliance and Notices The job description outlines the general nature and essential duties and responsibilities of the role. It may not contain a comprehensive list of all duties, responsibilities, and qualifications.
This job adheres to ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. Employees may have access to confidential information and must comply with HIPAA and the company’s privacy and security policies.
Employees must comply with the company’s Code of Business Conduct, including applicable laws, regulations, policies, and training requirements.
Pay Pay Range Minimum: $126,400.00
Pay Range Maximum: $236,000.00
Base pay is determined by qualifications, experience, and other factors; the salary range may vary by location and market.
Highmark Health and its affiliates prohibit discrimination and strive for accessibility. For accommodation requests, contact HR Services Online at HRServices@highmarkhealth.org. Req ID: J267196
#J-18808-Ljbffr