Director Reimbursement Design & Market Evaluation

Overview

Company:
Highmark Inc.

Job Description:

The role supports the matrixed strategic design and analytical approach to reimbursement. The incumbent will work with stakeholders across the enterprise to develop and implement an integrated roadmap for new and innovative reimbursement models across Highmark's markets and lines of business. The role requires aligning new models to the health plan's strategic objectives based on trends in commercial and government reimbursement.

The team will support the development and maintenance of models that drive ROI and other payer partnership decisions, identify gaps in operational capabilities, build requirements for new capabilities, and tie them to Highmark s strategic capability roadmap. Collaboration across teams is needed to inform and influence change to drive adoption and ROI realization. Key partners include Advanced Analytics, Contracting, Market and Provider Support teams, Actuary, Finance, Highmark Health Solutions, Health Plan Operations.

• Perform management responsibilities to include hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control day-to-day department operations; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
• Develop the conceptualization, strategy alignment, financial models, and high-level design of new reimbursement models for government and private payers. Programs include fee for service, pay-for-value, episode payments, prospective bundled payments, gain share and risk share models across all lines of business. Develop and maintain a 3-5 year strategic roadmap outlining current and future reimbursement designs with input from key executives. Stay informed of developments in public and private reimbursement, including CMS innovations, to ensure proactive strategy alignment.
• Work in a Health Economist framework to build and maintain analytical models that evaluate reimbursement models. Continuously evaluate models and seek improvements based on data and market research. Collaborate with Contracting and Provider Relation Leaders to develop targeted reimbursement models that support enterprise strategic initiatives.
• Develop and maintain strategic provider relationships to understand current healthcare delivery, readiness for change, and to communicate market transformation concepts with provider and professional advocacy societies and thought leaders. Serve as a subject matter expert with provider relations and clinical transformation consultants to explain programs and results to providers.
• Other duties as assigned or requested.

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

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 providers to source key capabilities
• 2 years Proven experience 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 contract management

Required

• None

Preferred

• None

• Excellent written and oral communication skills with the ability to present complex information clearly and persuasively, including leadership skills to relate to all levels of management and staff as well as external individuals
• 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…