Medicare Advantage Quality Consultant

Highmark Inc. Medicare Advantage Quality Consultant

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 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 interdepartmental 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 stakeholders to provide the most appropriate support to the PCPs based upon data analysis and dashboard reports.

This is a hybrid based role based in Buffalo New York - Onsite T, W, Th.

Essential Responsibilities :

• Directly responsible to provide office-based, hands-on assistance services 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. This includes presentation of program results to both internal and external audiences, including practice and entity meetings.
• Participates in the development and presentation of instructional materials for internal and external audiences.
• Provide assistance to PCPs in the use of user interfaces, predictive 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. This includes cross-training in all of Highmark's value-based reimbursement programs to lend support as needed / defined by market outcomes.
• Serve as the clinical subject matter expert for PCP Medicare STARS, Medicaid HEDIS, and risk revenue programs for both internal and external Highmark key stakeholders. 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.

Education :

Required : Bachelor's Degree in a clinical or healthcare related field

Substitutions : 6 years of relevant experience in lieu of a Bachelor's Degree

Preferred : Master's Degree in a clinical or healthcare related field

Licenses or Certifications :

Required : None

Preferred : None

Experience :

Required : 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

Preferred : 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

Skills :

Travel Requirement : 50% - 75%

Language Requirement (other than English) : None

Physical, Mental Demands and Working Conditions :

Position Type : Office-Based

Teaches / Trains others regularly : Constantly

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

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 : Rarely

Lifting : 25 to 50 pounds : Rarely

Pay Range Minimum : $67,500.00

Pay Range Maximum : $126,000.00

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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