Highmark Health Clinical Transformation Consultant-Specialist (Western PA) 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 government value based reimbursement programs and continuous improvement models. This job is a highly skilled subject matter expert (SME) in Medicare STARS, Medicaid HEDIS and risk revenue streams and provides strategic, hands-on, office based support to PCPs for analysis of performance Medicare STARS, Medicaid HEDIS and risk revenue streams, identifies opportunities for improvement in value creation, cost control and utilization, performance, and develops strategic plans in collaboration with PCPs and the inter-departmental teams for transformation of workflows resulting in outstanding performance in government program(s) ensuring that ROI targets set by the Organization are met or exceeded. Further, in a matrix management environment, the CTC 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 support the Western PA territory and must reside in this territory. This person will be supporting Specialists as it relates to cost and quality. Incumbents coming from the hospital/PCP or clinical space will be considered.

*This is a work from home role requiring travel >80% of the time to the Specialist's locations.


  • Directly responsible to provide office based, hands-on assistance services (i.e. chart reviews, mass claims adjustments, UDC processes, etc.) to PCPs enrolled in Medicare STARS, Medicaid HEDIS and risk revenue 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 government programs.

  • Directly responsible to analyze and interpret data in government value based reimbursement reports in the areas of Medicare STARS, Medicaid HEDIS and risk revenue and develop strategic plans to meet PCP government 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 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 the Organization's representative subject matter expert in government value based reimbursement programs and data analysis. This includes presentation of program results to both internal and external audiences, including practice and entity meetings.

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

  • Provide assistance to PCPs in the use of user interfaces, predicative analytic tools, and other population health management tools endorsed by Highmark.

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

  • Serve as the clinical subject matter expert for PCP Medicare STARS, Medicaid HEDIS, and risk revenue programs for both internal and external Highmark key stake holders. In a matrix management environment, works collaboratively with the interdepartmental team to provide the most comprehensive support to PCPs for exemplary scores in government programs.

  • Other duties as assigned or requested.



  • Bachelor's Degree in a clinical or healthcare industry discipline or 6 years of relevant experience in lieu of a Bachelor's Degree


  • Master's Degree in a clinical or healthcare industry discipline



  • 5-7 years of work experience in Medicare/Medicaid and risk revenue, primary care and the ambulatory care environment, healthcare insurance industry government programs, healthcare administration in primary care, or healthcare consulting in government programs for primary care

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

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


  • PCP or hospital or clinical experience

  • 7-10 years of experience in a government program setting, 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/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity