Clinical Transformation Partner RN

Company :

Highmark Health

Job Description : 

JOB SUMMARY 

This job works directly with network providers to support key clinical transformation programs with a focus on utilization of appropriate care. The team member works with internal and external stakeholders to ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.  The team member will also work with providers to identify specific areas of improvement within the same domain and help providers develop meaningful action plans to improve performance.  The team member is responsible for building relationships, engaging clinicians, educating on Utilization Management policies and processes, developing workflows and resources, and improving provider performance.  

 
ESSENTIAL RESPONSIBILITIES 

• Review provider performance according to accepted and established criteria, as well as other approved guidelines and medical policies. 
• Analyze qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction.
• Educate providers and other relevant external stakeholders on medical policy clinical criteria used to authorize care on a proactive basis.
• Develop and sustain positive working relationships with internal and external customers.
• Respond to customer inquiries and offers interventions and/or alternatives.
• Other duties as assigned or requested.

EXPERIENCE 

Required 

• 5 years experience in any of the following healthcare areas:  the provider environment (hospital, facility, PCP, specialist, supporting area(s)), or healthcare insurance industry, or healthcare administration in a provider office, hospital and/or health systems, or healthcare consulting in provider setting.
• 3 years of experience in utilization management/care management/QA/managed care ​

 
Preferred 

• 3 years of experience in data analysis, interpretation, and outcomes strategic plan development.
• 1 year of lean, six sigma, TQI, TQC or other quality and/or project management certification

​

SKILLS 

• Ability to analyze data, measure outcomes, and develop action plans
• Working knowledge of pertinent regulatory and compliance guidelines and medical policies
• Ability to multitask and perform in a fast-paced and often intense environment that requires flexibility
• Excellent written and verbal presentation skills, excellent interpersonal and negotiation skills, and ability to positively influence others.  Engages with external stakeholders with a professional demeanor and customer-centered mindset.
• Be a team player who possesses strong analytical and organizational skills.

EDUCATION 

Required 

• Bachelor’s degree in nursing OR licensed RN with associate's degree or RN diploma.

Preferred 

• None

 
LICENSES or CERTIFICATIONS 

Required 

• Registered Nurse (RN) license in PA; additional states may be required.

Preferred 

• PA Driver's license
• Certification in nursing area of expertise

Language (Other than English): 

None 

Travel Requirement: 

0% - 25% 

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS 

Position Type 

Office- or Remote-based 

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 

No 

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 job 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 es