Medicare Advantage Quality Consultant - NEPA Region

Company : Highmark Health Job Description : JOB SUMMARY This job is directly responsible for the value creation, impact and cost control and fiscal/ROI targets as set by the Organization, including revenue stream outcomes, and engagement of primary care providers (PCP) enrolled in government value-based reimbursement programs and continuous improvement models.
This job is a highly skilled subject matter expert (SME) in Medicare STARS, Medicaid HEDIS and risk revenue streams and provides strategic, hands-on, office based support to PCPs for analysis of performance Medicare STARS, Medicaid HEDIS and risk revenue streams, identifies opportunities for improvement in value creation, cost control and utilization, performance, and develops strategic plans in collaboration with PCPs and the inter-departmental teams for transformation of workflows resulting in outstanding performance in government program(s) ensuring that ROI targets set by the Organization are met or exceeded.
Further, in a matrix management environment, the Medicare Advantage Quality Consultant is responsible for collaborative work with other functions in the provider area, data analytics, and key internal/external stake holders to provide the most appropriate support to the PCPs based upon data analysis and dashboard reports.
ESSENTIAL RESPONSIBILITIES Directly responsible to provide office based, hands-on assistance services (i.
e.
, chart reviews, mass claims adjustments, UDC processes, etc.
) to PCPs enrolled in Medicare STARS, Medicaid HEDIS and risk revenue programs and clinical evidence-based guidelines.
The Medicare Advantage Quality Consultant is expected to assess the needs of each individual PCP practice, and use a combination of on-site individual office based, entity level based, video conference, teleconference, and electronic mail interactions to drive engagement and exemplary value creation, impact and cost control, and ROI/fiscal outcomes as set by the Organization for government programs.
Directly responsible to analyze and interpret data in government value-based reimbursement reports in the areas of Medicare STARS, Medicaid HEDIS and risk revenue and develop strategic plans to meet PCP government program targets to create value, impact, and cost savings, as well as meeting the ROI as identified by the Organization.
Directly responsible to assess data for highest ROI opportunities in PCP performance and implement strategic plans to meet identified program targets across all the Organization's value-based programs for both the commercial and government business (ACA, Medicare STARS, Medicaid HEDIS, risk revenue).
Function as the Organization's representative subject matter expert in government value-based reimbursement programs and data analysis.
This includes presentation of program results to both internal and external audiences, including practice and entity meetings.
Participates in the development and presentation of instructional materials for internal and external audiences.
Provide assistance to PCPs in the use of user interfaces, predicative analytic tools, and other population health management tools endorsed by Highmark.
Independently and autonomously manage PCP caseloads, projects, meetings, deliverables, resources etc.
for individualized strategic plans to transform PCP practices enrolled in government programs using innovative continuous improvement methodologies.
This includes cross training in all of Highmark’s value-based reimbursement programs to lend support as needed/defined by market outcomes.
Serve as the clinical subject matter expert for PCP Medicare STARS, Medicaid HEDIS, and risk revenue programs for both internal and external Highmark key stake holders.
In a matrix management environment, works collaboratively with the interdepartmental team to provide the most comprehensive support to PCPs for exemplary scores in government programs.
Other duties as assigned or requested.
EDUCATION Required Bachelor's Degree in a clinical or healthcare related field Substitutions 6 years of relevant experience in lieu of a Bachelor's Degree Preferred Master's Degree in a clinical or healthcare related field LICENSES OR CERTIFICATIONS Required None Preferred None EXPERIENCE Required 5 years in Medicare/Medicaid and risk revenue, primary care and the ambulatory care environment, healthcare insurance industry government programs, healthcare administration in primary care, or healthcare consulting in government programs for primary care 3 years in data analysis, interpretation, and outcomes strategic plan development Experience with Medicare STARS, Medicaid HEDIS, risk revenue value streams, and population health management Preferred 7 years in a government program setting, managed care, primary care management or other clinical setting Experience in Lean, Six Sigma, TQI, TQC or other quality management certification Experience in health plan provider network performance management, population health management, continuous improvement or provider engagement models SKILLS Must be able to effectively resolve issues and problems across all areas of the corporation, by understanding corporate strategies, policy and scope of authority Because of the broad impact of decisions that are made, must be knowledgeable and sensitive to many internal and external corporate issues Aptitude for a high visibility position demanding integrity, uncompromising professionalism, diplomacy and conflict management Demonstrates a deep understanding of primary care practice operations and workflow across the continuum of variability in primary care and experience in managing provider and administrative leadership relationships Superior written and verbal communication skills and listening skills Ability to adapt engagement strategies to meet market needs Travel Requirement 50% - 75% Language Requirement (other than English) None PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type Office-Based Teaches/Trains others regularly Constantly Travels regularly from the office to various work sites or from site-to-site Frequently Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply Physical Work Site Required No Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Rarely 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 job 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.
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