Director Reimbursement Design & Market Evaluation

Overview Highmark Inc. – Job Summary : This job supports the matrixed strategic design and analytical approach to reimbursement. The incumbent will work closely with stakeholders across the enterprise in the development and implementation of an integrated roadmap for the introduction and delivery of new and innovative reimbursement models across Highmark's markets and lines of business. This requires aligning new models to the health plan's strategic objectives based on trends in both commercial and government lines of business. The team will support development and maintenance of models that drive ROI and other decisions on payer partnership constructs, identify operational gaps, build requirements to drive new capabilities, and tie them to Highmark's strategic capability roadmap. The role requires effective collaboration across teams to inform and influence change to drive adoption and ROI realization. Critical partners include Advanced Analytics, Contracting, Market and Provider support teams, Actuary, Finance, Highmark Health Solutions, Health Plan Operations.

Do not pass up this chance, apply quickly if your experience and skills match what is in the following description.

Essential Responsibilities

Perform management responsibilities including hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.

Develop the overall conceptualization, strategy alignment, financial models, and high-level design of new reimbursement models for government and private payers. Programs include but are not limited to fee for service, pay-for-value programs, episode payments, prospective bundled payments, gain share and risk share models across all lines of business with the goal of maximizing quality while reducing healthcare costs. Develops and maintains a 3-5 year strategic roadmap outlining current and future reimbursement designs across markets and lines of business with input from key executives across the organization. Stay abreast of new developments in the public and private reimbursement space, including CMS innovations, to ensure seamless integration and strategic competitiveness.

Utilize a Health Economist approach to build and maintain analytical models that evaluate reimbursement models. Continuously evaluate models and seek innovative improvements based on data and market research. Collaborate with Contracting and Provider Relation Leaders and others to develop targeted reimbursement models that support enterprise strategic initiatives outside planned value-based designs or as a focus of innovation.

Develop and maintain strategic provider relationships to understand the current healthcare delivery state, readiness for change, test value-based programming concepts, identify key partners, and communicate market transformation concepts with provider and professional advocacy societies and key thought leaders. Serve as a subject matter expert with provider relations and clinical transformation consultants to explain new programs and results to provider partners.

Other duties as assigned or requested.

Education Required

Bachelor's Degree in Business, Finance, Healthcare Administration, or Related Field

Substitutions

6 years of relevant work experience

Preferred

Master's Degree in Business or Healthcare Administration

Experience Minimum

7 years Healthcare, Healthcare Insurance, Consulting or related area

3 years Value-based reimbursement, through managed care contracting, provider reimbursement, consulting, population health delivery or related areas

4 years Research and strategic planning around emerging trends in reimbursement, network, and payment model design. Demonstrate the application of healthcare economic drivers and / or population health based analytics

To include

1 year Experience working with technology vendors, and other service provider solutions to source key capabilities

2 years Proven experience in working in a Health Economist capacity driving understanding of current health trends.

Preferred

5 years Familiarity with alternative care model designs (e.g., patient centered medical home, ACO), alternative reimbursement models (e.g., bundled payments), and provider / health plan quality programs (e.g. pay for performance)

5 years Familiarity with the delivery of health care services across the continuum and quality metrics.

5 years Experience in running large cross organizational programs and projects

5 years Familiarity with health plan and provider contracting or revenue management

2 years Understanding of provider contract documents and overall contract management process

Licenses or Certifications Required

None

Preferred

None

Skills

Excellent written and oral communication skills with the ability to present complex information clearly and persuasively. Includes leadership skills and ability to relate to all levels of management, staff, and external stakeholders

Highly effective oral and written communications skills

Ability to manage multiple, complex projects within prescribed timelines

Proficient in MS Office suite, including Word, Excel, PowerPoint and project management software

High level of autonomy and self-direction to guide reimbursement model design from concept through execution

Ability to navigate a complex organization and engage multiple stakeholders to achieve reimbursement objectives

Strong financial background and analytical skills with a deep understanding of the economic drivers of healthcare

Comfort with real-time calculations of cost, membership, etc. (i.e., back-of-the-envelope estimations)

Language : (Other than English)

None

Travel Requirement

0% - 25%

Physical, Mental Demands and Working Conditions Position Type : Office-based. Typically entails teaching / training others; travel regularly from the office to various work sites or site-to-site; works primarily out-of-the-office (not selling products / services). Physical requirements include lifting up to 10 pounds frequently, 10-25 pounds occasionally, and 25-50 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 part of responsibilities, employees may have access to confidential information and must comply with HIPAA and the company’s privacy and information security policies.

Employees must comply with the company’s Code of Business Conduct and applicable laws, rules, and regulations.

Pay Range Minimum : $126,400.00

Maximum : $236,000.00

Base pay is determined by qualifications, experience, and other factors. The salary range shown may vary by location.

Highmark Health and its affiliates prohibit discrimination against qualified individuals and provide accessibility information. For accommodations, contact HR Services Online at HRServices@highmarkhealth.org. Req ID : J267196

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