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

Highmark Health•Pittsburgh, PA

About The Position

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 outstanding performance 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.

Requirements

Bachelor's Degree in a clinical or healthcare related field
6 years of relevant experience in lieu of a Bachelor's Degree
RN
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
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%

Nice To Haves

Master's Degree in a clinical or healthcare related field
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

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.
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.
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.
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.