Company :Highmark Inc.Job Description :
JOB SUMMARY
Role requires the incumbent to:
- Lead and manage a team of interoperability and risk adjustment SMEs: Provide guidance, mentorship, and support to team members, fostering a collaborative and high-performing environment.
- Develop and implement strategies for data integration and interoperability: Collaborate with internal and external stakeholders to identify and address data exchange challenges, ensuring accurate and timely data flow across systems.
- Oversee risk adjustment processes and ensure compliance with regulations: Stay abreast of evolving regulatory requirements and implement best practices to ensure accurate risk adjustment calculations and reporting.
- Drive continuous improvement initiatives: Identify opportunities to enhance data quality, streamline processes, and optimize outcomes
- Collaborate with IT and other departments: Work closely with IT teams to ensure seamless data integration and system compatibility, and partner with other departments to address interoperability challenges.
- Develop and maintain comprehensive documentation: Create and maintain clear documentation of interoperability and risk adjustment processes, policies, and procedures.
- Analyze data and identify trends: Utilize data analytics to identify patterns, trends, and potential areas for improvement in interoperability and risk adjustment.
- Present findings and recommendations to leadership: Communicate findings and recommendations to senior management, providing insights and actionable strategies to optimize data quality and risk adjustment.
The incumbent works closely with senior/executive leadership, Physicians and technical staff within the Enterprise, data vendors, and within strategic hospital partners, to identify, prioritize, and deliver large and small scale projects that advance business outcomes and achieve strategic objectives relative to new improving Highmark's interoperability capabilities.
Supports other key objectives designed to build/strengthen patient care delivery and capture of Risk Adjustment documentation/ reporting capabilities, as well as driving continuous improvement efforts. Will be responsible for professional coaching and mentoring of program team members.
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.
- Lead the day-to-day execution of Strategic Risk Adjustment Program engagements taking ownership of the engagement deliverables, resources, and outcomes.
- Develop the engagement business case, scope, staffing and incentive model for RPM engagement with Providers on internal programs (UDC, Internal Chart Retrieval and RSA).
- Lead and manage project team members and/or external consultants by implementing and managing changes and interventions to ensure project goals are achieved.
- Work closely with executive project sponsors and stakeholders to make communication easy and transparent to ensure ongoing alignment with project objectives, activities, and outcomes.
- Regularly brief the executive leadership of the Enterprise (both Highmark and Highmark Health), including CFO, EVP, Chief Actuary, and Vice President, on project status including program strategy, performance, timelines, risks, and issues.
- Evaluate risks to risk adjustment programs goals and objectives and escalate as appropriate.
- Conduct periodic market review to understand industry leading practices and drive continuous improvement in department approaches, methods, and tools and organizational awareness of department capabilities.
- Other duties as assigned or requested.
EDUCATION
Requied
- Bachelor's Degree in Business Administration/Management or Computer and Information Science
Substitutions
- Six (6) years relevant and progressive experience in lieu of Bachelor's degree
Preferred
- Master's Degree in Business Administration/Management or Mental Health Services
EXPERIENCE
Required
- 7 - 10 years Project / Program Management
To Include
- 3 - 5 years Leadership
- 3 - 5 years Risk Revenue
- 1 - 3 years Strategic Planning
Preferred
- 3 - 5 years Healthcare Industry
- 1-3 years Healthcare Data Management or Interoperability
- 1 -3 years Consulting
- 1 -3 years Cross-Functional Project Teams
LICENSES or CERTIFICATIONS
Required
- None
Preferred
- Project Management Professional (PMP)
SKILLS
- Excellent Multi-Tasker
- Analytical and Logical Reasoning/Thinking
- Information Technology
- Enterprise Systems
- Financial Statements
Language (Other than English)
None
Travel Requirement
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-Based
Teaches / trains others regularly
Occasionally
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)
Rarely
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 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:
$92,300.00
Pay Range Maximum:
$170,800.00
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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The 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.
