Resp & Qualifications
CareFirst is a not-for-profit corporation which is the largest health insurer in the mid-Atlantic region with more than 3 million Members, 5,000 associates and more than $10 billion in spending in CareFirst’s service area. The company is regarded as a top employer in many surveys and offers competitive salary and benefits.
The Practice & Payment Transformation team grew out of a successful and mature Practice Consulting / Practice Transformation function which has supported providers in the PCMH Program for over 8 years. As the company’s strategy has taken value-based care beyond Primary Care, the Payment Transformation function was added in 2019.
The team is currently staffed with public health, business and finance experts with extensive experience in value-based models, practice transformation, and practice economics. Including a medical director on the team will accelerate and advance our Practice & Payment Transformation efforts within the provider community. This Medical Director will partner with Practice Consultants in both Primary Care and Specialty disciplines, value-based model experts, and enterprise-level health system managers to help with model design and to drive both structural enhancements to provider groups and clinical improvements in practice workflow.
Under the general direction of the Vice President, Practice & Payment Transformation, the incumbent’s responsibilities include, but are not limited to, providing leadership, and oversight as follows:
1. Represent Practice & Payment Transformation to the CareFirst Provider Network Internal and External Stakeholders
• Acts as subject matter expert on all aspects of value-based care and supporting clinical programs including Care Management, Disease Management, Wellness, Transition of Care, Patient-Centered Medical Home (PCMH), Ancillary, Pharmacy Management, and other clinical programs.
• Interprets and implements policies and procedures to monitor overall efficiency and adherence standards for CareFirst.
• Develops and implements programs for education of affiliated clients and provider groups
• Close working relationship with the Chief Medical Officer and Medical Director team
• Liaison to other departments and divisions on behalf of the Practice & Payment Transformation team.
• Serves as clinical and administrative resource and ensures adherence to policies, procedures and external regulatory agencies.
• Works with Medical Policy, Quality, Care Management, PCMH, Wellness, Pharmacy and Dental management areas to anticipate provider group and client account needs and provide innovative solutions in response to national and local care management trends.
2. Value-Based Program Development Support
• Provide expertise to payment transformation team with regard to value-based model development with specific focus on clinical episode definitions and necessary exclusions.
• Collaborate with Quality to develop and maintain quality measurement requirements in value-based programs
• Partner with Actuary, Finance, Quality, Medical Economics, Networks, and Payment Transformation in work groups evaluate and monitor value-based programs value-based program models.
• Work with Payment Transformation team and other departments as needed to develop reporting for presentation to internal stakeholders and external provider groups.
3. Internal Coaching and Consulting
• Collaborates with internal stakeholders to identify and prioritize high impact opportunities for savings that may span product development, provider payment policies, clinical programs, care management or other operational units.
• Consult with Practice Consultants, Payment Transformation team, and Networks as well as other Medical Affairs departments in strategizing practice transformation and clinical innovation efforts.
• Provide subject matter and clinical expertise in the form of division-wide trainings, small group meetings, and one-on-ones
4. Support Program Evaluation
• Work with the Payment Transformation Team, IT, Finance and Actuarial to identify program strengths and weaknesses for future improvement.
• Develop actionable insights and recommendations based on trend evaluations.
• Provide thoughtful insight to identify and mitigate clinical risks or unintended consequences that CareFirst’s new payment programs may cause.
• Medical Degree from an accredited medical school, completion of an American residency program required with postgraduate training.
• Board Certification
• Current license to practice in Maryland without restriction.
• Minimum of 2 years of experience in clinical practice.
• Minimum of 3 years of experience in managed care, consulting, value-based program management, or related field.
• Demonstrated experience with conducting and facilitating presentations to senior level stakeholders.
• General understanding of health care claims data, trend analysis, and insurance operations and products.
• An in-depth knowledge of all aspects of current and emerging group-based trends in care management.
• Knowledge of accreditation standards and federal/state regulations relating to quality improvement.
• Proven track record of collaborative, analytic problem solving. An ability to present and discuss analytical information in a way that is persuasive and advances understanding.
• An ability to provide insights and actionable improvements for model and program design, based on analytic findings.
• Thrives in a highly matrixed, cross-functional environment. Strong interpersonal skills, with the ability to effectively influence and collaborate with employees and management at all levels.
• Critical thinking and judgment
• Ability to lead/coordinate projects and act as a resource to other CareFirst departments;
• Highly effective written and interpersonal communication skills, including executive level presentation skills.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
• Mixed clinical experience in independent and health system-owned environments.
• Related Graduate degree such as MBA, MPH
• 5 years of experience in managed care, consulting, value-based care, or related field.
Practice and Payment Innovation
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 09/21/2019
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described below are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. The associate must frequently travel to other CareFirst BlueCross BlueShield locations.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship