Director Provider Reimbursement Development

Company :Highmark Inc.Job Description : 

JOB SUMMARY

This job is responsible for the direction and oversight of the departmental functions relating to provider reimbursement including research, development, implementation, ongoing operational maintenance and administration of provider payment methodologies and fee schedules for all provider types in support of provider contractual arrangements.  Additional responsibilities of this job include the development and integration of provider payment policies and guidelines applicable to institutional and professional reimbursements and in concert with the Organization's products and member benefits.  This job will partner closely in the pay for value reimbursement designs, and will contribute to the support other corporate short and long term strategic initiatives. These functions collectively maintain the Organization's reimbursements to all health care providers, and serve as a consulting resource in maintaining the Organization's application service providers (ASP) partner plans.

ESSENTIAL RESPONSIBILITIES

• Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
• Maintains all institutional reimbursement methodologies leveraged by the Organization and ASP partners.  This includes demonstrating deep knowledge in industry standard payment methods, including but not limited to: diagnostic related groups (DRG) weight-based methods, ambulatory payment classifications (APCs), fee schedules and other customized methods in support of contractual commitments.
• Maintains all professional reimbursement methodologies leveraged by the Organization and ASP Partners.  This includes demonstrating deep knowledge in professional fee development for annual, quarterly and interim updates.  This will also include deep understanding of industry standard methodologies, including but not limited to: resource based relative value scale (RBRVS), anesthesia, ancillary payment models and any other fee for service models.
• Demonstrates working knowledge in the design and roll out of alternative payment methods that are focused on an incentive based pay for value approach.  This will require partnering cross organizationally to support the development of these new programs, and direct the operational activities necessary to stand them up.
• Works across the organization to aid to develop and manage payment policy across the organization.  This includes assessment and recommendations for payment policies for all provider reimbursements that follow industry and corporate level guidelines.  Will also play a key roll in the assisting the ASP partners in maintaining their policies.
• Researches and provides recommendations on development of new or enhancements to existing reimbursements in conjunction with corporate and contractual initiatives including sound financial modeling/impact analyses.
• Operates as the divisional lead for the corporate affordability strategy, working collaboratively across all the the Organization's  markets to identify, track and implement identified initiatives.
• Other duties as assigned or requested.

REQUIRED EDUCATION

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

Substitutions

Experience in the healthcare industry and in provider payment and data analysis, strategic planning and financial management in lieu of Bachelor's degree

PREFERRED EDUCATION

Master's Degree - Business, Finance, Healthcare Administration or other related field.

EXPERIENCE

Minimum

• 8 years' of healthcare industry experience that includes 5 years' of extensive experience in provider payment and data analysis, strategic planning and financial management, with 3 years' staff, team lead or project lead experience
• Strong financial background and analytical skills with a deep understanding of the economic drivers of healthcare
• Understanding of new and emerging trends in reimbursement and payment model design
• Familiarity with core health plan reimbursement operations

Preferred

• 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)
• Familiarity with the delivery of health care services across the continuum and quality metrics.
• Experience working with technology vendors, and other service provider solutions to source key capabilities
• Comfort and with real-time calculations of cost, membership, etc. (i.e., “back of the envelope” estimations)

KNOWLEDGE, SKILLS & ABILITIES

• Excellent leadership skills, with the ability to relate to all levels of management and staff as well as individuals external to the corporation
• Excellent written and oral communication skills with the ability to present complex information clearly and persuasively
• 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 to execution
• Ability to successfully navigate complex organization, engaging multiple stakeholders to achieve reimbursement objectives

REQUIRED LICENSURE

None

PREFERRED LICENSURE

None

TRAVEL REQUIREMENT:  0% - 25%
 

LANGUAGE REQUIREMENT (other than English):
None

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
 

Position Type:

Office-based

Teaches/Trains others regularly

Frequently

Travels regularly from the office to various work sites or from site-to-site

Rarely

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

Occasionally

Lifting: 25 to 50 pound

Rarely

ADDITIONAL INFORMATION

Changes Approved By:

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

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. 

Pay Range Minimum:

$108,000.00

Pay Range Maximum:

$201,800.00

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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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