Highmark Health
Director Reimbursement Design & Market Evaluation
Highmark Health, Annapolis, Maryland, United States, 21403
Overview
Company :
Highmark Inc. Job Description : This job 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 new and innovative reimbursement models across Highmark's markets and lines of business. The role aligns 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 supports development and maintenance of models that drive ROI and other decisions on payer partnership constructs. The role identifies operational gaps, builds requirements for new capabilities, and ties them to Highmark's strategic capability roadmap. Collaboration across teams is required 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.
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 government and private payers. Programs include fee-for-service, pay-for-value, 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. Develop and maintain a 3-5 year strategic roadmap for reimbursement designs with input from executives. Stay abreast of developments in both public and private reimbursement spaces to ensure alignment with strategy.
Operate in a Health Economist approach to build and maintain analytical models evaluating reimbursement designs. Continuously evaluate models and seek improvements based on data and market research. Collaborate with Contracting and Provider Relations to develop targeted reimbursement models that support enterprise initiatives that may fall outside planned value-based designs or serve as a focus of innovation.
Develop and maintain strategic provider relationships to understand current healthcare delivery, readiness for change, test value-based programming concepts, identify key partners, and communicate market transformation concepts with provider and professional advocacy groups and thought leaders. Serve as a subject matter expert with provider relations and clinical transformation consultants to explain 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
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; demonstrates 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 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 healthcare services across the continuum and quality metrics
5 years Experience in 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 processes
Licenses or Certifications
Required
None
Preferred
None
Skills
Excellent written and oral communication skills with the ability to present complex information clearly and persuasively. Includes strong leadership and the ability to relate to all levels of management, staff, and external partners.
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 execution
Ability to navigate a complex organization and engage multiple stakeholders to achieve reimbursement objectives
Strong financial background and analytical skills with a deep understanding of the economic drivers of healthcare
Comfort with real-time calculations of cost, membership, etc.
Travel
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 (sales employees) – Not applicable
Physical work site required: Yes
Lifting: up to 10 pounds – Constant
Lifting: 10 to 25 pounds – Occasionally
Lifting: 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 of employees to do this job.
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. All employees must comply with HIPAA and data security guidelines as described in company privacy policies and information security policy.
Employees must comply with the company’s Code of Business Conduct and applicable laws, rules, and policies.
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 does not reflect geographic differentials that may apply.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on protected status and require accessibility; contact HR for accommodations if needed.
Req ID: J267196
#J-18808-Ljbffr
Company :
Highmark Inc. Job Description : This job 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 new and innovative reimbursement models across Highmark's markets and lines of business. The role aligns 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 supports development and maintenance of models that drive ROI and other decisions on payer partnership constructs. The role identifies operational gaps, builds requirements for new capabilities, and ties them to Highmark's strategic capability roadmap. Collaboration across teams is required 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.
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 government and private payers. Programs include fee-for-service, pay-for-value, 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. Develop and maintain a 3-5 year strategic roadmap for reimbursement designs with input from executives. Stay abreast of developments in both public and private reimbursement spaces to ensure alignment with strategy.
Operate in a Health Economist approach to build and maintain analytical models evaluating reimbursement designs. Continuously evaluate models and seek improvements based on data and market research. Collaborate with Contracting and Provider Relations to develop targeted reimbursement models that support enterprise initiatives that may fall outside planned value-based designs or serve as a focus of innovation.
Develop and maintain strategic provider relationships to understand current healthcare delivery, readiness for change, test value-based programming concepts, identify key partners, and communicate market transformation concepts with provider and professional advocacy groups and thought leaders. Serve as a subject matter expert with provider relations and clinical transformation consultants to explain 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
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; demonstrates 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 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 healthcare services across the continuum and quality metrics
5 years Experience in 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 processes
Licenses or Certifications
Required
None
Preferred
None
Skills
Excellent written and oral communication skills with the ability to present complex information clearly and persuasively. Includes strong leadership and the ability to relate to all levels of management, staff, and external partners.
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 execution
Ability to navigate a complex organization and engage multiple stakeholders to achieve reimbursement objectives
Strong financial background and analytical skills with a deep understanding of the economic drivers of healthcare
Comfort with real-time calculations of cost, membership, etc.
Travel
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 (sales employees) – Not applicable
Physical work site required: Yes
Lifting: up to 10 pounds – Constant
Lifting: 10 to 25 pounds – Occasionally
Lifting: 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 of employees to do this job.
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. All employees must comply with HIPAA and data security guidelines as described in company privacy policies and information security policy.
Employees must comply with the company’s Code of Business Conduct and applicable laws, rules, and policies.
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 does not reflect geographic differentials that may apply.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on protected status and require accessibility; contact HR for accommodations if needed.
Req ID: J267196
#J-18808-Ljbffr