Company :Highmark Inc.Job Description :
JOB SUMMARY
This role leads a team of quality staff responsible for driving high-quality utilization management (UM) assessments across all Highmark product lines (commercial, Medicare Advantage, ACA, CHIP), encompassing non-clinical, medical, pharmacy, and behavioral health domains. The successful candidate will be a strategic leader with proven analytical, project management, and communication skills, focused on optimizing UM performance and driving continuous improvement initiatives. This is a highly analytical role requiring expertise in data analysis, process improvement methodologies, and program development.
ESSENTIAL RESPONSIBILITIES
- Team Leadership & Management:
- Provide direct supervision to a team of quality focused staff, including recruitment, training, performance management, coaching, development, compensation, and recognition.
- Oversee daily operations, ensuring adherence to policies, procedures, and quality standards.
- Foster a culture of continuous improvement and high-performance within the team
Program Development & Management:
- Develop and implement comprehensive UM quality improvement programs aligned with organizational strategic objectives and regulatory requirements.
- Design and deploy robust performance monitoring systems, including key performance indicators (KPIs) related to medical necessity, cost-effectiveness, and adherence to clinical guidelines.
- Develop and maintain detailed program documentation, including processes, workflows, and training materials.
- Lead the development and implementation of new UM programs and initiatives.
- Strategic Planning & Execution:
- Collaborate with the Director to develop and implement the department’s strategic plan, aligning with organizational goals and objectives.
- Regularly monitor and report on the plan’s progress to internal and external stakeholders, including regulatory bodies and business partners.
- Quality Performance Improvement:
- Oversee UM organization-wide quality improvement processes.
- Analyze performance data, identify areas for improvement, and develop and implement interventions to enhance quality and revenue.
Cross-Functional Collaboration & Stakeholder Management:
- Collaborate extensively with clinical, pharmaceutical, operational, IT, and quality improvement teams to ensure seamless integration and alignment of UM programs across the enterprise.
- Effectively communicate program status, progress, and challenges to diverse stakeholders, including executive leadership and external partners.
- Data Analysis & Reporting:
- Conduct in-depth analyses of UM performance data across all product lines to identify trends, opportunities for improvement, and areas of risk.
- Develop and implement data-driven interventions to improve quality, efficiency, and cost-effectiveness of UM processes.
- Develop and maintain comprehensive reporting mechanisms to track KPIs and communicate findings to stakeholders (including executive leadership, regulatory bodies, and business partners)
- Project Management: Oversee multiple projects simultaneously, managing timelines, budgets, and resources effectively. Escalate risks and dependencies to executive leadership as needed.
- Process Improvement: Continuously evaluate existing processes and implement improvements to enhance efficiency and effectiveness.
EDUCATION
Required
- Bachelor's Degree in Business Administration/Management or Health Care Related field
Substitutions
- High School Diploma with 6 years of experience
Preferred
- Master's Degree in Business Administration/Management or Health Care Related field
EXPERIENCE
Required
- 3 - 5 years of Quality Improvement experience
- 1 - 3 years of Project Management experience
- 1 - 3 years of Process Design experience
- 1 - 3 years of Process Improvement experience
Preferred
- Proven experience managing a team of quality auditors or a similar role in healthcare
- Strong understanding of utilization management principles
- Excellent analytical, problem-solving, and data interpretation skills
- Proficiency in project management methodologies
- Strong communication, interpersonal, and presentation skills
- 3 - 5 years of Strategic Planning experience
- 1 - 3 years of Operational Excellence experience
- 1 - 3 years of Medicare experience
- 1 - 3 years of Medicaid experience
- 1 - 3 years of Management experience
LICENSES OR CERTIFICATIONS
Required
- None
Preferred
- None
SKILLS
- Analytical Skills
- Performance Improvement
- Project Management
- Collaboration
- Written & Oral Presentation Skills
- Team Leadership
- Strategic Thinking
- Budget Management
- Healthcare Industry
- Vendor Management
Languages (other than English)
None
Travel Required
0% to 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
Occasionally
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Occasionally
Lifting: 10 to 25 pounds
Rarely
Lifting: 25 to 50pounds
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 position 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:
$78,900.00
Pay Range Maximum:
$147,500.00
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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What We Do
Highmark Health, a Pittsburgh, PA based enterprise that employs more than 40,000 people who serve millions of Americans across the country, is the second largest integrated health care delivery and financing network in the nation based on revenue. Highmark Health is the parent company of Highmark Inc., Allegheny Health Network, and HM Health Solutions. Highmark Inc. and its subsidiaries and affiliates provide health insurance to nearly 5 million members in Pennsylvania, West Virginia and Delaware as well as dental insurance, vision care and related health products through a national network of diversified businesses that include United Concordia Companies, HM Insurance Group, and Visionworks. Allegheny Health Network is the parent company of an integrated delivery network that includes eight hospitals, more than 2,800 affiliated physicians, ambulatory surgery centers, an employed physician organization, home and community-based health services, a research institute, a group purchasing organization, and health and wellness pavilions in western Pennsylvania. HM Health Solutions focuses on meeting the information technology platform and other business needs of the Highmark Health enterprise as well as unaffiliated health insurance plans by providing proven business processes, expert knowledge and integrated cloud-based platforms.
A national blended health organization, Highmark Health and our leading businesses support millions of customers with products, services and solutions closely aligned to our mission of creating remarkable health experiences, freeing people to be their best.
Headquartered in Pittsburgh, we're regionally focused in Pennsylvania, Delaware, West Virginia and New York, with customers in all 50 states and the District of Columbia.
We passionately serve individual consumers and fellow businesses alike. Our companies cover a diversified spectrum of essential health-related needs, including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative technology solutions.
We’re also proud to carry forth an important legacy of compassionate care and philanthropy that began more than 170 years ago. This tradition of giving back, reinvesting and ensuring that our communities remain strong and healthy is deeply embedded in our culture, informing our decisions every day.
