Clinical Design Specialist

Job ID: J124478
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jun 5, 2018

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Description

JOB SUMMARY (Summarizes the major purpose and primary responsibilities)

This job supports the design team in research, design and development of new clinical programs, enhancements and expansion of existing programs, and expansion of clinical programs into new markets within Gateway Health Plan and will support all lines of business. The incumbent may lead a team to complete a design project, or may act as the representative for clinical design team on a larger company wide initiative.  The role will work side by side with the implementation team for smooth transitions to sustain the programs that were developed and will work closely with internal and external stakeholders and must be able to represent Gateway in the community.

ESSENTIAL RESPONSIBILITIES (Describes the critical tasks, duties and responsibilities of the position.)

  • Responsible for serving as the subject-matter expert for clinical responses to request for proposals (RFPs) to support growth and expansion.  This may include: researching specific state programs, requirements related to the proposal, best practices in the proposed state or environment, as well as reading and interpreting RFP related draft agreements/contracts, preparing written responses, coordinating subject matter expert (SME) responses.
  • Work closely with other departments to assess needs for new or enhanced programs, achieve company-wide and clinical department's specific initiatives, works with legal and compliance on contract development and regulatory compliance of new programs.
  • Based on literature review and research, designs clinical programs that are best practice, needed to meet regulatory requirements, consistent with triple aim initiatives or overall improvement to member or provider deliver systems.
  • Design programs that are best practice, needed to meet regulatory requirements, consistent with triple aim initiatives or overall improvement to member or provider deliver systems.
  • Direct and communicate with external contractors to support compliance and program/initiative roll-outs.  This may include assisting in vetting vendors to fulfill specific program requirements or enhancements to program delivery.
  • Represent the company at community and provider events related to expansion and new initiatives, including presentation of Gateway's plans for initiatives and related education. Collaborate/communicate with medical directors and other department managers to assure integration and coordination of new programs with the clinical areas, grievance, and quality improvement departments' ongoing programs and new initiatives.
  • Provide education internally on new program design and impact to specific departments.
  • Other duties as assigned or requested.

REQUIRED EDUCATION

Bachelor's Degree - Business, Healthcare Administration or other related area

Substitutions (Acceptable substitutions in lieu of a degree 1 ½ years’ experience  = 1 year college)

No Substitutions

PREFERRED EDUCATION

Master’s Degree - Business, Healthcare Administration or other related area

EXPERIENCE

Minimum: This section refers to the minimum years and type of applicable experience needed to perform the job.  Minimum requirements must be non-comparative, objective, and relevant.

  • 5 - 7 years' experience in healthcare, specifically with the Medicaid and dual eligible populations
  • Experience working in a managed care environment
  • Experience leading a team

Preferred: This section refers to additional desired years and type of experience that the hiring manager would prefer, above and beyond the basic requirements of the job.

  • 10 - 15 years' experience in healthcare

KNOWLEDGE, SKILLS & ABILITIES (List the attributes required to perform the job through demonstrated service, education or training)

  • Ability to both lead a team or project while interacting well with peers, supervisors, customers and vendors
  • Ability to read, and interpret contractual requirements and make sound recommendations to meet those requirements
  • Ability to solve problems independently and creatively while being proactive, self-directed, assertive and creative in problem solving and system planning
  • Ability to handle many tasks simultaneously and appropriately triage issues with minimal supervision
  • Possess good written and oral communication skills
  • Have an appreciation of cultural diversity and sensitivity towards the Medicaid population with demonstrated expertise in topics related to cultural competency. Be aware of issues members face by members in all LOB including barriers to care such as transportation, child care, lack of knowledge concerning preventive health, distrust of the system as well as other personal, social, financial barriers
  • Possess the ability to examine best practices, evaluate data, trends, provider opinions and member awareness for the purpose of trouble shooting and problem solving and proposing tangible plans for improvements

REQUIRED LICENSURE (Licenses that are required to perform the job)

None

PREFERRED LICENSURE

Certification in Case Management (CCM), Registered Nurse (RN) or Licensed Social Worker (LSW)

TRAVEL REQUIREMENT:
0% - 25%

LANGUAGE REQUIREMENT (other than English)?  
(List primary language)

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
(The physical, mental demands and working conditions described here are representative of those that must be met by an employee to successfully perform the essential function of their job. Reasonable accommodations will be made when necessary to enable individuals with disabilities to perform the essential duties of the position, to the extent that they do not cause undue hardship.

Position Type:

Office-Based

Office-Based Positions

An employee in this position works in an office environment.  The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Teaches/Trains others regularly  

Occasionally

Travels 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)  Does Not Apply

Physical Work Site Required  

Yes

Most On-The-Road Positions

An employee in this position may work in a home or company office environment but is also frequently driving to and from various locations to perform the work off-site.  The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Non-Office-Based Positions

An employee in this position is frequently required to move throughout the workplace, sit, stand and walk, use hands and fingers to hold objects, tools or controls, possess fine motor skills (e.g., to write and operate a computer or to steer transportation equipment), possess gross motor skills (e.g., to carry items), reach with hands and arms, climb stairs and ladders, balance, stoop, kneel crouch and crawl, communicate effectively, and talk and hear. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.  The employee must be able to work in a busy environment where decisions often must be made quickly, must attend work on a regular and reliable basis, must adhere to all workplace policies, and may be called upon to work outside regular business hours.  This work occurs in a [example: warehouse, hospital or provider’s office or mailroom].

Lifting: up to 10 pounds  

Never

Lifting: 10 to 25 pounds  

Never

Lifting: 25 to 50 pounds  

Never

ADDITIONAL INFORMATION

Changes Approved By:

Melanie Lysne

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

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