Gateway Health Plan
Job Description :I. GENERAL OVERVIEW:
The Director, Population Health Strategies will focus on ensuring enterprise-wide improvement in clinical quality measures by directing the activities and analytics associated with those improvements using innovative population health strategies and public health resources. Primary responsibility is to directly lead Gateway staff in the development, implementation, monitoring, and follow through for the Health Plan’s clinical quality programs and initiatives to ensure Gateway achieves its objectives for HEDIS, Medicare STARs, and NCQA Accreditation status. This includes leading a team of clinical and non-clinical professionals to work with various departments across the corporation and to direct multidisciplinary quality teams comprised of internal staff and/or external network providers to ensure interventions are fully developed and implemented.
This role also includes leading efforts in developing and implementing population health strategies that leverage all aspects of managed care including care management, utilization management, physician practice management and alignment, and private and public community agency collaborations.
The Director will oversee and lead the Solutions Research and Development team, which is responsible for designing and developing new strategies, as well as Health Services Analytics team, which is responsible for measuring the effectiveness of those strategies and making adjustments based on analytics.
II. ESSENTIAL RESPONSIBILITIES:
1. Directs and is accountable for professional staff, both clinical and nonclinical, which is responsible for ensuring improvement in clinical outcomes based on population health strategies developed. This includes handling quantitative and qualitative analysis to identify improvement opportunities, and implementing interventions to improve member care. Activities apply to the Delaware, Pennsylvania and West Virginia markets as well as Medicare markets in OH, PA, KY, and NC.
2. Directs and is accountable for professionals who lead multidisciplinary groups of individuals throughout the enterprise to develop interventions and direct provider-based and internal Gateway committees to advance member health outcomes. This involves action plan development, timelines, large-scale complex multi-pronged interventions, and communication strategies for complex issues with large impact on the organization and its members. These activities impact Gateway’s market standing and sales efforts and include the corporate expectation of continual improvement in Gateway’s ratings across all lines of business and in all service regions.
3. Directs professional team members in their advisory roles to departments across the corporation in order to revise and enhance enterprise-wide interventions to affect positive changes in Health Plan member health care. This requires up-to-date knowledge of current and upcoming trends in population health strategies and the ability to correctly identify root cause barriers and develop cost-effective interventions across the Gateway service area to improve care.
4. Directs and leads professional staff that ensures corporate compliance with accreditation and regulatory standards for continuity and coordination of medical care and behavioral health care activities. This includes development and implementation of clinical research, analysis, identification of improvement opportunities and implementation of interventions. Responsible for maintaining information and corporate history regarding the analysis and ongoing activities in place to meet compliance. Applies to Delaware, Pennsylvania and West Virginia markets. Impacts Gateway’s compliance with NCQA, Medicare Advantage, Pennsylvania Department of Health, West Virginia Insurance Commissioner’s Office and Delaware Insurance Department requirements.
5. Directs and leads professional staff in developing and implementing research design, inclusive of methodology for analyzing healthcare data on projects and/or initiatives. Manages and resolves methodological, coding, and data issues that arise during project implementation and analysis.
6. Other duties as assigned or requested.
- Bachelor’s Degree in Nursing or Public Health
- Five (5) years’ experience with continuous quality improvement processes including project planning and managing multiple priorities
- Five (5) years of experience interpreting regulations and assessing plan impact, implementing processes to enhance compliance, and auditing results
- Five (5) of leadership experience
- Three (3) years of experience leading or implementing strategies to improve outcomes for low income and/or underserved populations.
- Strong analytic skills and a broad working knowledge of current health insurance accreditation guidelines and applicable government regulations
- Master’s Degree in Business Administration, Public Health or health-related field is preferred
- At least three years’ experience working in an outpatient clinical setting
- Current RN license for applicable State
Knowledge, Skills and Abilities
- Proven leadership skills – ability to influence and motivate others to achieve results
- Passion for excellence
- Strong and effective verbal and written communication skills
- Ability to present complex topics in a concise manner
- Broad understanding of business issues, metrics, organizational linkages and customer value
- Excellent analytical skills, with the ability to assess scenarios based on real-world applications
- Successful experience in achieving results through people in a complex environment
- Ability to motivate professional staff to meet strict project and reporting deadlines
- Strong knowledge of Highmark and its diversified businesses and the on-going company strategy
- Ability to focus on details, but with an overall understanding of the business
- Ability to provide sound project direction, interact effectively with senior management and others within the corporation,
and facilitate project assessments, present findings, status and recommendations in a professional manner
- Must be methodological in problem resolution while considering multiple resources both inside and outside the company
and multiple tasks
- Ability to recognize and balance business and operational constraints without jeopardizing compliance
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
If yes, indicate the number of direct reports:
V. WORK ENVIRONMENT
Is Travel Required?
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, 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, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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