Medicare Advantage Quality Consultant - Registered Nurse (Western, PA)

Description

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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 outstandingperformance 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

• RN

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

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 any category protected by applicable federal, state, or local law.

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