Highmark Health
Director Reimbursement Design & Market Evaluation
Highmark Health, Topeka, Kansas, United States, 66652
Overview
Company: Highmark Inc. Job Description: JOB SUMMARY This role supports the matrixed strategic design and analytical approach to reimbursement. The incumbent will work with stakeholders across the enterprise to develop and implement an integrated roadmap for introducing and delivering new and innovative reimbursement models across Highmark markets and lines of business. The role aligns new models to the health plan's strategic objectives based on innovations and industry trends in both commercial and government lines of business. The team supports development and maintenance of models that drive ROI and other decisions on payer partnership constructs, identifies operational gaps, builds requirements for new capabilities, and ties them to Highmark's strategic capability roadmap. The role works across teams to inform and influence change to drive adoption and ROI realization. Critical partners include Advanced Analytics, Contracting, Market and Provider support teams, 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 department 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 government and private payers. Programs include but are not limited to fee-for-service, pay-for-value, episode payments, prospective bundled payments, gain share and risk share models across all lines of business. Develops and maintains a 3-5 year strategic roadmap outlining current and future reimbursement designs with input from key executives. Stay informed of new developments in public and private reimbursement space, including CMS innovations, to ensure seamless integration with the organization’s strategy.
Utilize a Health Economist approach to build and maintain analytical models evaluating reimbursement designs. Continuously evaluate models and seek innovative improvements based on data and market research. Collaborate with Contracting and Provider Relations leaders and others to develop targeted reimbursement models that support enterprise strategic initiatives.
Develop and maintain strategic provider relationships to understand current healthcare delivery state, readiness for change, test value-based programming concepts and components, identify key partners, and communicate market transformation concepts with provider and professional advocacy societies and key thought leaders. Act as a subject matter expert with provider relations and clinical transformation consultants to explain new programs and results to providers.
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 Education
Master's Degree in Business or Healthcare Administration
Experience
Minimum: 7 years in Healthcare, Healthcare Insurance, Consulting or related area
3 years in Value-based reimbursement, through managed care contracting, provider reimbursement, consulting, population health delivery or related areas
4 years in research and strategic planning around emerging trends in reimbursement, network, and payment model design; understanding healthcare economic drivers and/or population health analytics
To include: 1 year experience working with technology vendors and other service providers to source key capabilities
2 years proven experience in a Health Economist capacity driving understanding of current health trends
Preferred Experience
5 years familiarity with alternative care model designs (e.g., patient-centered medical home, ACO) and alternative reimbursement models (e.g., bundled payments), and provider/health plan quality programs (e.g., pay for performance)
5 years familiarity with healthcare delivery 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 of provider contract documents and contract management process
Licenses or Certifications
Required: None
Skills
Excellent written and oral communication skills with the ability to present complex information clearly, plus leadership ability to relate to management, staff and external contacts
Highly effective oral and written communications
Ability to manage multiple, complex projects within prescribed timelines
Proficient in MS Office suite (Word, Excel, PowerPoint) and project management software
Autonomy and self-direction to guide reimbursement model design from concept to execution
Ability to navigate a complex organization and engage multiple stakeholders to achieve reimbursement objectives
Strong financial background and analytical skills with deep understanding of healthcare economic drivers
Comfort with real-time calculations of cost and membership
Language
None
Travel Requirement
0% - 25%
Physical, Mental Demands and Working Conditions
Position Type: Office-based
Teaches/trains others regularly
Travel regularly from the office to various work sites or site-to-site
Works primarily out of the office selling products/services
Physical work site required: Yes
Lifting: up to 10 pounds frequently; 10 to 25 pounds occasionally; 25 to 50 pounds rarely
Disclaimer: The job description indicates 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.
Compliance Requirement: This job adheres to 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 confidential information and must protect it. All employees must comply with HIPAA laws and the company privacy policies and information security policy. All employees must comply with the company Code of Business Conduct, as well as applicable federal and state laws, rules, and regulations, and company policies and training requirements.
Pay Range Minimum: $126,400.00
Pay Range Maximum: $236,000.00
Base pay is determined by qualifications, experience, expected contributions, internal peer equity, market, and business considerations. The salary range does not reflect geographic adjustments Highmark may apply.
Highmark Health and its affiliates prohibit discrimination based on protected veteran or disability status and other protected categories. For accessibility or application assistance, contact HR Services Online at HRServices@highmarkhealth.org. Req ID: J267196
#J-18808-Ljbffr
Company: Highmark Inc. Job Description: JOB SUMMARY This role supports the matrixed strategic design and analytical approach to reimbursement. The incumbent will work with stakeholders across the enterprise to develop and implement an integrated roadmap for introducing and delivering new and innovative reimbursement models across Highmark markets and lines of business. The role aligns new models to the health plan's strategic objectives based on innovations and industry trends in both commercial and government lines of business. The team supports development and maintenance of models that drive ROI and other decisions on payer partnership constructs, identifies operational gaps, builds requirements for new capabilities, and ties them to Highmark's strategic capability roadmap. The role works across teams to inform and influence change to drive adoption and ROI realization. Critical partners include Advanced Analytics, Contracting, Market and Provider support teams, 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 department 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 government and private payers. Programs include but are not limited to fee-for-service, pay-for-value, episode payments, prospective bundled payments, gain share and risk share models across all lines of business. Develops and maintains a 3-5 year strategic roadmap outlining current and future reimbursement designs with input from key executives. Stay informed of new developments in public and private reimbursement space, including CMS innovations, to ensure seamless integration with the organization’s strategy.
Utilize a Health Economist approach to build and maintain analytical models evaluating reimbursement designs. Continuously evaluate models and seek innovative improvements based on data and market research. Collaborate with Contracting and Provider Relations leaders and others to develop targeted reimbursement models that support enterprise strategic initiatives.
Develop and maintain strategic provider relationships to understand current healthcare delivery state, readiness for change, test value-based programming concepts and components, identify key partners, and communicate market transformation concepts with provider and professional advocacy societies and key thought leaders. Act as a subject matter expert with provider relations and clinical transformation consultants to explain new programs and results to providers.
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 Education
Master's Degree in Business or Healthcare Administration
Experience
Minimum: 7 years in Healthcare, Healthcare Insurance, Consulting or related area
3 years in Value-based reimbursement, through managed care contracting, provider reimbursement, consulting, population health delivery or related areas
4 years in research and strategic planning around emerging trends in reimbursement, network, and payment model design; understanding healthcare economic drivers and/or population health analytics
To include: 1 year experience working with technology vendors and other service providers to source key capabilities
2 years proven experience in a Health Economist capacity driving understanding of current health trends
Preferred Experience
5 years familiarity with alternative care model designs (e.g., patient-centered medical home, ACO) and alternative reimbursement models (e.g., bundled payments), and provider/health plan quality programs (e.g., pay for performance)
5 years familiarity with healthcare delivery 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 of provider contract documents and contract management process
Licenses or Certifications
Required: None
Skills
Excellent written and oral communication skills with the ability to present complex information clearly, plus leadership ability to relate to management, staff and external contacts
Highly effective oral and written communications
Ability to manage multiple, complex projects within prescribed timelines
Proficient in MS Office suite (Word, Excel, PowerPoint) and project management software
Autonomy and self-direction to guide reimbursement model design from concept to execution
Ability to navigate a complex organization and engage multiple stakeholders to achieve reimbursement objectives
Strong financial background and analytical skills with deep understanding of healthcare economic drivers
Comfort with real-time calculations of cost and membership
Language
None
Travel Requirement
0% - 25%
Physical, Mental Demands and Working Conditions
Position Type: Office-based
Teaches/trains others regularly
Travel regularly from the office to various work sites or site-to-site
Works primarily out of the office selling products/services
Physical work site required: Yes
Lifting: up to 10 pounds frequently; 10 to 25 pounds occasionally; 25 to 50 pounds rarely
Disclaimer: The job description indicates 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.
Compliance Requirement: This job adheres to 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 confidential information and must protect it. All employees must comply with HIPAA laws and the company privacy policies and information security policy. All employees must comply with the company Code of Business Conduct, as well as applicable federal and state laws, rules, and regulations, and company policies and training requirements.
Pay Range Minimum: $126,400.00
Pay Range Maximum: $236,000.00
Base pay is determined by qualifications, experience, expected contributions, internal peer equity, market, and business considerations. The salary range does not reflect geographic adjustments Highmark may apply.
Highmark Health and its affiliates prohibit discrimination based on protected veteran or disability status and other protected categories. For accessibility or application assistance, contact HR Services Online at HRServices@highmarkhealth.org. Req ID: J267196
#J-18808-Ljbffr