Clinical Design Specialist

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This job supports the design team in research, design and development of new clinical programs, enhancements and expansion of existing programs, and expansion of clinical programs into new markets within Highmark Wholecare Health Plan and will support all lines of business. The incumbent may lead a team to complete a design project, or may act as the representative for clinical design team on a larger company wide initiative.  Works side by side with the implementation team for smooth transitions to sustain the programs that were developed and works closely with internal and external stakeholders and must be able to represent Highmark Wholecare in the community.

ESSENTIAL RESPONSIBILITIES

• Serve as the subject-matter expert for clinical responses to request for proposals (RFPs) to support growth and expansion.  This may include: researching specific state programs, requirements related to the proposal, best practices in the proposed state or environment, as well as reading and interpreting RFP related draft agreements/contracts, preparing written responses, coordinating subject matter expert (SME) responses.
• Work closely with other departments to assess needs for new or enhanced programs, achieve company-wide and clinical department's specific initiatives, works with legal and compliance on contract development and regulatory compliance of new programs.
• Utilize literature review and research to design clinical programs that are best practice, needed to meet regulatory requirements, consistent with triple aim initiatives or overall improvement to member or provider deliver systems.
• Direct and communicate with external contractors to support compliance and program/initiative roll-outs.  This may include assisting in vetting vendors to fulfill specific program requirements or enhancements to program delivery.
• Represent the company at community and provider events related to expansion and new initiatives, including presentation of Highmark Wholecare's plans for initiatives and related education. Collaborate/communicate with medical directors and other department managers to assure integration and coordination of new programs with the clinical areas, grievance, and quality improvement departments' ongoing programs and new initiatives.
• Provide education internally on new program design and impact to specific departments.
• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor's Degree in Business, Healthcare Administration or other related area

Substitutions

• 6 years of experience in Business, Healthcare Administration or other related area

Preferred

• Master’s Degree - Business, Healthcare Administration or other related area

EXPERIENCE

Required

• 5 - 7 years in Healthcare, specifically with the Medicaid and dual eligible populations
• Experience working in a managed care environment
• Experience leading a team

Preferred

• 10 - 15 years in Healthcare

LICENSES AND CERTIFICATIONS

Required

• None

Preferred

One, or more, of the following

• Certification in Case Management (CCM)
• Registered Nurse (RN)
• Licensed Social Worker (LSW)

SKILLS

• Ability to both lead a team or project while interacting well with peers, supervisors, customers and vendors
• Ability to read, and interpret contractual requirements and make sound recommendations to meet those requirements
• Ability to solve problems independently and creatively while being proactive, self-directed, assertive and creative in problem solving and system planning
• Ability to handle many tasks simultaneously and appropriately triage issues with minimal supervision
• Possess good written and oral communication skills
• Have an appreciation of cultural diversity and sensitivity towards the Medicaid population with demonstrated expertise in topics related to cultural competency. Be aware of issues members face by members in all LOB including barriers to care such as transportation, child care, lack of knowledge concerning preventive health, distrust of the system as well as other personal, social, financial barriers
• Possess the ability to examine best practices, evaluate data, trends, provider opinions and member awareness for the purpose of trouble shooting and problem solving and proposing tangible plans for improvements

Language (Other than English)

None

Travel Requirement:
0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches/Trains others regularly  

Occasionally

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

Works primarily out-of-the office selling products/services (Sales employees)  Does Not Apply

Physical Work Site Required  

Yes

Lifting: up to 10 pounds  

Never

Lifting: 10 to 25 pounds  

Never

Lifting: 25 to 50 pounds  

Never

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 position 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 established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$57,700.00

Pay Range Maximum:

$106,700.00

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 their race, color, age, 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, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

EEO is The Law

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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Salary : $57,700 - $106,700