JOB SUMMARY

This job serves as the primary relationship owner and executive liaison for strategically aligned provider groups within the Highmark Network. The incumbent is wholly accountable for managing and optimizing assigned provider relationships across large, complex entities-including ancillary networks, independent physician organizations, and integrated delivery networks.

Acting as a dedicated strategic partner, the incumbent is responsible for supporting and executing Value-Based Reimbursement (VBR) performance improvement initiatives while actively identifying and driving Total Cost of Care (TCOC) reduction opportunities. This role maintains a highly visible presence in the provider community and collaborates across matrixed internal health plan departments, regional representatives, and external partners to enforce quality compliance (STAR/HEDIS), maximize operational efficiencies, and ensure the mutual financial and clinical success of our shared value-based programs.

ESSENTIAL RESPONSIBILITIES

Value-Based Reimbursement Support

• Assume a leading role in the VBR activities, education, and implementation of new tools for all assigned providers.
• Drive high-level interactions and support the value-based programs. Communicate with the appropriate business leaders on the VBR program participation, opportunity, performance, and progress. Engage appropriate resources, tools, analytics, and reports to enable success in the programs to drive better health outcomes, lower unit costs, and higher patient satisfaction for our members.
• Responsible for educating providers on initiatives focused on managing medical expenses and maximizing HEDIS and STAR metrics in collaboration with internal resources.

General Provider Support

• Lead and manage relationship with assigned providers to proactively measure, anticipate and prevent problems as well as continually improve operational efficiencies and achieve corporate objectives around programs and strategic initiatives with providers. Educate providers on changes to reimbursement policies, processing requirements, and new technology offerings. Meet with contacts at various levels at key providers to ensure appropriate levels of communication and maintain harmonious relationships.
• Lead and manage relationship with assigned providers to proactively measure, anticipate and prevent problems as well as continually improve operational efficiencies and achieve corporate objectives around programs and strategic initiatives with providers. Proactively identify provider issues; recommends solutions and ensures provider communicates the necessary support and resources to carry out solutions.
• Ensure critical and timely communication to providers through on-going personal contacts, on-site field visits, regional communication sessions, and meetings with professional organizations to communicate initiatives and changes.

Internal Partnership

• Coordinate in a matrixed liaison role with contracting, operations, and support areas to ensure the appropriate development and execution of initiatives, communication needs, and issue resolution. Triage and addresses issues raised by providers and routes communications to the appropriate area for handling.
• May act as a conduit back to internal teams for provider input and feedback. Supports development and implementation of policy changes and communicates the provider perspective when representing the department on cross-functional teams, corporate initiatives, and tactical objectives.
• Maintain current market knowledge, industry knowledge and innovation awareness to drive the change needed to transform the way healthcare is delivered and reimbursed.
• Other duties as assigned or requested.

EXPERIENCE

Required

• 7 years of experience in healthcare / insurance industry
• 3 years of experience in presenting concepts to varying audiences
• 3 years of Project management experience or other relevant experience with high accountability for managing multiple tasks with defined deadlines

Preferred

• 5 years of experience in presenting concepts to varying audiences
• 5 years of Project management experience or other relevant experience with high accountability for managing multiple tasks with defined deadlines

SKILLS

• In depth understanding of the provider community (market knowledge) and global understanding of care delivery models and the insurance industry.
• Knowledge of reimbursement methodologies and models as well as financial and analytical modeling.
• Public speaking skills.
• Process/quality improvement and issue resolution skills.
• Strong written and oral communication and organizational/project management skills
• Broad knowledge and working experience with various software packages such as Microsoft PowerPoint, Excel, Word.
• Knowledge of required compliance with Centers of Medicaid and Medicare services (CMS) laws and regulations, policies and guidelines regarding Medicare Advantage and Medicaid plans; HIPAA privacy and security regulations.

EDUCATION

Required

• Bachelor's degree in Business, Healthcare related field or relevant experience and/or education as determined by the company in lieu of bachelor's degree.

Preferred

• None

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• None

Language (Other than English):

None

Travel Requirement:

Less than 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Hybrid

Teaches / trains others

Occasionally

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

Rarely

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

Never

Physical work site required

Occasionally

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.