Value-Based Reimbursement Specialist

Posted on: 09-08-2025 04:59 PM PST

Job Description:

This job is responsible for key strategic initiatives for the Markets and Provider Transformation Organization supporting the matrixed teams that engage providers enrolled in the Organization’s value-based reimbursement programs and continuous improvement models
The incumbent plays different potential roles on a given project, to include elements of project leadership, problem-solving, data analytics, team development, communication, implementation, and project management
The incumbent often plays a central role in the development and execution of the strategy for a given initiative for transformation of workflows resulting in outstanding performance in the Organization’s value-based reimbursement programs ensuring that ROI targets as set by the Organization are met or exceeded
The position collaborates with various teams within data analytics and infrastructure to support the creation, optimization, and maintenance of self-service resources for providers, entities, and health systems within these programs
Works on multiple projects and has exposure to all parts of the Organization, and will play a supportive role in planning, communicating, and managing the market strategy
Participate in the development of strategic plans for the Enterprise and Markets and Provider Transformation and the key BU's for the Organization’s value-based reimbursement programs and continuous improvement models
Lead or support key strategic initiatives across Enterprise and Markets and Provider Transformation for the Organization’s value-based reimbursement programs and continuous improvement models
Role will vary depending on initiative, but will include elements of team leadership, problem-solving, data analysis, project management, communication, implementation, and provider and/or provider-facing team education support
Will participate on a portfolio of projects
Serve as a subject matter expert working in concert with provider-facing teams to explain new programs and results to key provider partners as needed
Collaborate on product development and the creation, optimization, and maintenance of a self-service platform for providers, entities, and health systems within the Organization’s value-based reimbursement programs for both the commercial and government business with a focus on enterprise goals including but not limited to Government Markets (STARS, ACA, CHIP, Medicaid DE) and Enterprise Quality, Safety, and Values (Health Outcomes Measures)
Provide actionable opportunities in provider transformation aimed at high-quality, cost-effective care while improving patient outcomes
Provide consultative workflow transformation and training/education services to matrixed teams supporting providers enrolled in the organization's value-based reimbursement programs
Strong knowledge of risk adjustment methodologies and reporting/regulatory requirements and CMS Stars rating measures including HEDIS, CAHPS, Pharmacy, HOS, PQA, PQRS
Support development of the overall conceptualization, strategy alignment, and high-level design of new value-based reimbursement models for PCPs, specialists, and health systems across the Organization's footprint, based on deep understanding and knowledge of trends in other areas of the country with both government and private payers
Programs will include but not be limited to pay-for-value programs, episode payments, prospective bundled payments, gain share and risk share models and will be implemented for the Organization's Medicare Advantage, Medicaid, ACA, and commercial populations with the goal of maximizing quality while reducing healthcare costs
Support the identification of initiative impacts with other strategic initiatives to ensure alignment of the overall strategy to support the quintuple aim
Provide feedback and collaborate with the analytics team to ensure data points are accurate and provide meaningful, actionable data
Provide support to matrixed teams in the use of predictive analytic tools, user interfaces, population health management tools and other data-based platforms endorsed by the Organization
Support the team in identifying, clarifying, and resolving complex issues critical to the success of the initiative and play a role in shaping the culture and skill set of the Markets and Provider Transformation Organization
Other duties as assigned or requested
Basic project management skills
Proactive in driving change and continuous improvement
Demonstrated influencing and teamwork skills
Teaches / trains others
Travel from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job
Compliance Requirement: This job 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

Job Requirements:

5 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 of experience in data analysis, interpretation, and outcomes strategic plan development
1 year experience with Medicare STARS, Medicaid HEDIS, risk revenue value streams, and population health management
Must be able to effectively resolve issues and problems across all areas of the corporation, by understanding corporate strategies, policy, and scope of authority
Because of the broad impact of decisions that are made, must be knowledgeable and sensitive to many internal and external corporate issues
Aptitude for a high visibility position demanding integrity, uncompromising professionalism, diplomacy and conflict management
Strong quantitative, analytical, and time management skills
Demonstrates a deep understanding of primary care practice operations and workflow across the continuum of variability in primary care and experience in managing provider and administrative leadership relationships
Superior written and verbal communication skills and listening skills
Ability to adapt engagement strategies to meet market needs
Bachelors in Clinical or healthcare industry discipline OR relevant experience and/or education as determined by the company in lieu of bachelor's degree
LICENSES or CERTIFICATIONS
None
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

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JOB-18679

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