Highmark Health Clinical Transformation Consultant-PCP in Pittsburgh, Pennsylvania



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 the Organization's value based reimbursement programs and continuous improvement models. This job is a highly skilled subject matter expert (SME) in the Organization's value based reimbursement PCP programs who provides strategic, hands-on, office based support to PCPs for analysis of performance in quality, cost and utilization scores, identifies opportunities, 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 the Organization's value based reimbursement PCP program(s), ensuring that ROI targets as set by the Organization are met or exceeded. Further, in a matrix management environment, the incumbent is responsible for collaborative work with other functions in the provider area, data analytics, and key internal/external stake holders to provide the most appropriate support to the PCPs based upon data analysis and dashboard reports.

**This person will travel >80% of the time to the designated territory.


  • Directly responsible to provide office based, hands on consultative workflow transformation and training/education services to PCPs enrolled in the Organization's value based reimbursement programs and clinical evidence based guidelines. The CTC is expected to assess the needs of each individual PCP practice, and use a combination of on-site individual office based, entity level based, video conference, teleconference and electronic mail interactions to drive engagement and exemplary value creation, impact and cost control, and ROI/fiscal outcomes as set by the Organization for PCP programs.

  • Directly responsible to analyze and interpret PCP value based reimbursement reports in the areas of National Quality Standards like NCQA, HEDIS, NQF, PQRS etc., and cost and utilization and develop strategic plans to meet PCP 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 the highest ROI opportunities in PCP performance, and implement strategic plans to meet identified program targets across all of the Organization's value based programs for both the commercial and government business (ACA, Medicare STARS, Medicaid HEDIS, risk revenue).

  • Function as Highmark’s representative SME in value based reimbursement programs and data analysis. This includes presentation of program results to both internal and external audiences, including practice and entity meetings

  • Participatein the development and presentation of instructional materials for internal and external audiences.

  • Providefeedback to and collaborates with data analytics to ensure PCP reports are accurate, and provide meaningful, actionable data to PCPs.

  • Provide assistance to PCPs seeking accreditation programs/processes with NCQA, Joint Commission, URAC, AAAHC etc., and in the use of health information data exchanges, user interfaces, predicative analytic tools, and other population health management tools endorsed by the Organization.

  • Independently and autonomously manage PCP caseloads, projects, meetings, deliverable, resources etc. for individualized strategic plans to transform PCP practices enrolled in value based reimbursement program(s) using innovative continuous improvement methodologies. This includes cross training in all of the Organization's value based reimbursement programs to lend support as needed/defined by market outcomes.

  • Serve as the clinical SME for PCP value based reimbursement programs for both the Organization's internal and external key stake holders. In a matrix management environment, works collaboratively with the interdepartmental team to provide the most comprehensive support to PCPs for full practice transformation.

  • Other duties as assigned or requested.


Bachelor's Degree- Clinical or healthcare industry discipline or 6 years related experience in lieu of Bachelor's Degree


Master's Degree - Clinical or healthcare industry discipline



  • 5-7 years of work experience in the primary care and the ambulatory care environment, healthcare insurance industry, healthcare administration in primary care, or healthcare consulting in primary care or population health management

  • 3 years experience in data analysis, interpretation, and outcomes strategic plan development

  • Experience with Medicare STARS, Medicaid HEDIS, risk revenue value streams, and population health management


  • 7-10 years of experience in a 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


Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled