This job is the primary liaison between large/complex provider groups in the Organization network and the corporation. Will be responsible for cultivating relationships with large/complex provider groups to gain buy in and “sell” strategic initiatives for the purposes of piloting and implementing alternative care/reimbursement models. This job will maintain visibility in the provider community by representing the organization at various provider functions, meetings, and collaboratives. The incumbent will play an active role in network management, training, monitoring and enforcement of company policies and procedures while increasing provider efficiencies; participate as a regional representative on key operational/product/medical management/reimbursement projects/initiatives that impact providers (i.e. oncology pathways, tele-medicine, convenience care); recruit and introduce the Pay for Value (P4V) programs to the physician network; and work collaboratively with the physician practices that contract into the programs to reinforce and improve quality, to enrich the patient experience and to reduce the overall cost of care for members.
- Assume a leading role in the education and implementation of the provider network and contracting strategies for all assigned providers.
- Lead and manage relationship with assigned providers to proactively measure, anticipate and prevent problems as well as continually improve operational efficiencies and achieve corporate objectives around programs and strategic initiatives with providers.
- Proactively identify provider issues; recommend solutions and ensure provider receives the necessary support and resources to carry out the solutions.
- Coordinate in a matrixed liaison role with operations and support areas to ensure the appropriate development and execution of initiatives, communication needs, and issue resolution.
- Lead and manage activities to implement the provider network and contracting strategies for the large/complex provider groups within the region.
- Partner with key provider groups to gain buy-in and “sell” strategic initiatives for the purposes of piloting and implementing alternative care/reimbursement models.
- Act as a conduit back to project teams for provider input and feedback on strategic initiatives.
- Work to gain consensus and incorporate necessary plan modifications.
- Assist with contracting as it relates to implementing key provider strategies.
- Drive the high level interactions and direction of the Pay for Value (P4V) relationships.
- Communicate with the appropriate business leaders on the P4V program participation, opportunity, performance, and progress.
- Engage appropriate resources, tools, analytics, and reports to enable success in the programs to drive better health outcomes, lower unit costs, and higher patient satisfaction for our members.
- Oversee administration of critical and timely communication to providers through ongoing personal contacts, on-site field visits, regional communication sessions, and meetings with professional organizations to communicate initiatives and changes.
- Develop, participate in, and support education to providers due to changing reimbursement environment, product portfolio, processing requirements, and new technology offerings.
- Meet with contacts at various levels at key physician practices to ensure appropriate levels of communication and maintain harmonious relationships.
- Maintain current market knowledge, industry knowledge and innovation awareness to drive the change needed to transform the way healthcare is delivered and reimbursed.
- Collect market intelligence to contribute to strategic planning and design of products and networks.
- Other duties as assigned or requested.
- Bachelor's Degree - Business, Healthcare related field
- Prior experience in provider relations, healthcare or insurance industry
- 5 - 7 years of experience in the healthcare/insurance industry
- 3 - 5 years of experience in presenting concepts to varying audiences
- 3 - 5 years of project management experience or other relevant experience with high accountability for managing multiple tasks with defined deadlines
LICENSES AND CERTIFICATIONS
- In-depth understanding of the provider community (market knowledge) and global understanding of care delivery models and the insurance industry
- Knowledge of reimbursement methodologies and models as well as financial and analytical modeling
- Public speaking/delivering presentations
- Negotiation skills
- Process/quality improvement
- Strong written and oral communication and organizational/project management skills
- Broad knowledge and working experience with various software packages such as Microsoft PowerPoint, Excel, Word
- Knowledge of required compliance with Centers of Medicaid and Medicare services (CMS) laws and regulations, policies and guidelines regarding Medicare Advantage and Medicaid plans; HIPAA privacy and security regulations
25% - 50%
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
Teaches/Trains others regularly
Travels regularly from the office to various work sites or from site-to-site
Physical Work Site Required
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.
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, 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, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org