Highmark Health Director, Population Health in Pittsburgh, Pennsylvania


General Overview:

This job has ownership and directional leadership of three primary Workstreams: leadership over the Population Health Performance Specialist team, who is responsible for the outcomes of providers contracted in the Organization's gain / risk share arrangements, the ownership, development, and direction of population health clinical programs such as Behavioral Health and Disease Management, as well as the management of resources permanently embedded in AHN. Further, in a matrix management environment, the incumbent will be responsible for ensuring collaborative work with the other members of the value-based reimbursement team, provider relations, senior markets, analytics, actuary, and key internal/external stake holders to provide the most appropriate support for providers with gain / risk share contracts, as well as the successful implementation and execution of assigned care management programs. The incumbent will be responsible for the overall clinical support needed to ensure entities success in new value-based reimbursement arrangements, and will be expected to manage the needs of each entity in respect to population health data and analytics, strategic suggestions, and overall education on successful workflow adjustments to increase probability of success in futuristic value-based arrangements.

Essential Job Functions:

  • Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.

  • Manage and develop the process of supporting providers contracted in the Organization's gain/risk share programs, with a goal of maximizing quality and ROI for the Organization. Ensure team reaches predetermined ROI targets for the given entities. Set goals and expectations around the use of performance reports and data to inform decision-making, process, and program implementation, as well as the development of process interventions based on practice-level data, trends and identified opportunities. Inclusive of, but not limited to: Advise primary care practices, physicians, nurses and other clinical staff to assist them on their conversion to value-based care; Disseminate and interpret quality and efficiency reports.

  • When relevant, disseminate and support gap closures for STARS and improved coding for government populations. Identify process improvement gaps in workflow and develop individualized plans to remedy. Provide educational and training sessions. Create and maintain relationships with specialists and/or hospital resources for providers employed in multi-specialty groups or health systems.

  • For value based contracts address government markets, directly responsible for the quality improvement and cost savings outcomes as a result of workflow transformation, superior coding accuracy, and Medicare STARS gap closure to providers based upon each individual gain/risk share contract parameters. This includes analysis and interpretation of claims submission for superior coding accuracy, cost and utilization reports, medical loss ratio reports, Medicare STARS gaps and other risk revenue opportunities.

  • Function as the Organization's key contact on gain/risk share multi-disciplinary team. This includes presentation of program results to both internal and external audiences, including practice and entity meetings with the value-based reimbursement multi-disciplinary team.

  • Develop overarching template and approach to presenting clinical support models that intertwine all stakeholders and maintain strategic direction of value-based contract. Participate in the development and presentation of instructional materials for internal and external audiences, educating others on the clinical support model designed for each entity.

  • Provide feedback to and collaborate with the analytics team to manage templates to ensure reports are accurate, and provide meaningful, actionable data. Provide assistance to providers at the c-suite level, supporting the specialist, in the use of predictive analytic tools, user interfaces, population health management tools and other data based platforms endorsed by the Organization.

  • Independently and autonomously manage gain/risk share contract caseloads, projects, meetings, deliverables, resources etc. for individualized strategic plans to ensure significant cost savings for provider contract holders using innovative continuous improvement methodologies. This includes cross training in all of Organization’s pay for value and value based reimbursement programs to lend support as needed/defined by market outcomes.

  • Support the development, monitoring of, and enhancement of person centered, evidenced based AHN CIN Population Health model that promotes the triple-aim including provider engagement. This model will be integrated with continuum based high performing resources and care pathways.

  • Develop person-centered comprehensive care programs that support the triple-aim and complement the overall value strategy for our providers. Such integrated care programs include but not limited to, Behavioral Health, Diabetes Management, etc.

  • Other duties as assigned or requested.

Minimum Qualifications:

  • High School Diploma/GED with Registered Nurse License (RN)


  • Bachelor's Degree in Business Administration/Management, Finance or Health Administration

  • 7 - 10 years in the Healthcare Industry

  • 7 - 10 years in Operation Excellence

  • 3 - 5 years in Management

Preferred Qualifications:

  • 3 - 5 years in Data Analytics, Lean/Six Sigma or Contract Administration

  • 1 - 3 years in Finance

Knowledge, Skills & Abilities:

  • Problem Solving & Decision Making

  • Relationship-builder with Unsurpassed Interpersonal Skills

  • Operations Management

  • Provider Management

  • Healthcare Information Technology

Licenses & Certifications:

  • Registered Nurse (RN)

Referral Award Payout Level: 2


Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity