Manager Strategic Risk Adjustment Programs

Company :Highmark Inc.Job Description : 

JOB SUMMARY

Role requires the incumbent to:

• Lead and manage a team of interoperability and risk adjustment SMEs: Provide guidance, mentorship, and support to team members, fostering a collaborative and high-performing environment.
• Develop and implement strategies for data integration and interoperability: Collaborate with internal and external stakeholders to identify and address data exchange challenges, ensuring accurate and timely data flow across systems.
• Oversee risk adjustment processes and ensure compliance with regulations: Stay abreast of evolving regulatory requirements and implement best practices to ensure accurate risk adjustment calculations and reporting.
• Drive continuous improvement initiatives: Identify opportunities to enhance data quality, streamline processes, and optimize outcomes
• Collaborate with IT and other departments: Work closely with IT teams to ensure seamless data integration and system compatibility, and partner with other departments to address interoperability challenges.
• Develop and maintain comprehensive documentation: Create and maintain clear documentation of interoperability and risk adjustment processes, policies, and procedures.
• Analyze data and identify trends: Utilize data analytics to identify patterns, trends, and potential areas for improvement in interoperability and risk adjustment.
• Present findings and recommendations to leadership: Communicate findings and recommendations to senior management, providing insights and actionable strategies to optimize data quality and risk adjustment.

The incumbent works closely with senior/executive leadership, Physicians and technical staff within the Enterprise, data vendors, and within strategic hospital partners, to identify, prioritize, and deliver large and small scale projects that advance business outcomes and achieve strategic objectives relative to new improving Highmark's interoperability capabilities.

Supports other key objectives designed to build/strengthen patient care delivery and capture of Risk Adjustment documentation/ reporting capabilities, as well as driving continuous improvement efforts. Will be responsible for professional coaching and mentoring of program team members.

ESSENTIAL RESPONSIBILITIES

• Perform 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. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
• Lead the day-to-day execution of Strategic Risk Adjustment Program engagements taking ownership of the engagement deliverables, resources, and outcomes.
• Develop the engagement business case, scope, staffing and incentive model for RPM engagement with Providers on internal programs (UDC, Internal Chart Retrieval and RSA).
• Lead and manage project team members and/or external consultants by implementing and managing changes and interventions to ensure project goals are achieved.
• Work closely with executive project sponsors and stakeholders to make communication easy and transparent to ensure ongoing alignment with project objectives, activities, and outcomes.
• Regularly brief the executive leadership of the Enterprise (both Highmark and Highmark Health), including CFO, EVP, Chief Actuary, and Vice President, on project status including program strategy, performance, timelines, risks, and issues.
• Evaluate risks to risk adjustment programs goals and objectives and escalate as appropriate.
• Conduct periodic market review to understand industry leading practices and drive continuous improvement in department approaches, methods, and tools and organizational awareness of department capabilities.
• Other duties as assigned or requested.

EDUCATION

Requied

• Bachelor's Degree in Business Administration/Management or Computer and Information Science

Substitutions

• Six (6) years relevant and progressive experience in lieu of Bachelor's degree

Preferred

• Master's Degree in Business Administration/Management or Mental Health Services

EXPERIENCE

Required

• 7 - 10 years Project / Program Management

To Include

• 3 - 5 years Leadership
• 3 - 5 years Risk Revenue
• 1 - 3 years Strategic Planning

Preferred

• 3 - 5 years Healthcare Industry
• 1-3 years Healthcare Data Management or Interoperability
• 1 -3 years Consulting
• 1 -3 years Cross-Functional Project Teams

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• Project Management Professional (PMP)

SKILLS

• Excellent Multi-Tasker
• Analytical and Logical Reasoning/Thinking
• Information Technology
• Enterprise Systems
• Financial Statements

Language (Other than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

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

Occasionally

Works primarily out-of-the office selling products/services (sales employees) 

Rarely

Physical work site required  

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

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 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:

$92,300.00

Pay Range Maximum:

$170,800.00

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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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