This position facilitates programs related to medical management, performance-based arrangements, and managed care programs. Interfaces with all levels of staff, health plans and physicians. Develops processes and implementation activities required to launch payer projects. Coordinates across all levels of the organization to implement solutions. This may include oversight of national and commercial performance measures, including but not limited to Medicare Stars Rating (Stars), Healthcare Effectiveness Data and Information Set (HEDIS), Accountable Care Organization (ACO) measures and Risk Adjustment Factor (RAF) metrics for Medicare Advantage and Commercial business.
Serves as a program facilitator for value based arrangement. Facilitation includes the development of implementation schedules, procedures and programs as well as implement and maintain the payer products including related goals and objectives. Ensures compliance with federal and state regulations, as well as established organizational policies and procedures.
Participates in the development and implementation of select payer programs, short and long-range goals and objectives and determines the optimal progression to obtain these goals. Reviews analyses and reports of various activities to determine progress toward goals and objectives.
Reviews, prepares, analyzes, and presents reports and recommendations to senior management to provide concise and accurate information that aids in decision-making. Develops, reviews, and monitors financial outcomes using performance metrics.
Acts as Liaison between assigned payer and the business. Monitors projects to develop best practices and identify process that are efficient and effective methods while ensuring compliance with payer guidelines. Identifies gaps in operations, implements solutions, and developing ongoing project changes.
Ensures risk adjustment (RA) accurately reflects the membership health profiles, as well as completeness of the Medicare risk adjustment data, to ensure compliance with all Centers for Medicare and Medicaid Services (CMS) regulations and guidelines.
Develops and maintains documentation to support consistent and accurate administration of the Risk Adjustment and Quality processes. Maintains a current professional and technical knowledge relating CMS and payer requirements and directives for Risk Adjustment and Quality to ensure policies and procedures meet compliance requirements.
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Medical Group with an excellent service experience by consistently demonstrating our core and leader behaviors each day.
Must possess a strong knowledge of business and/or healthcare as normally obtained through the completion of a bachelors degree in business, healthcare administration or related field.
Current license as a Registered Nurse.
Proficiency typically achieved with five or more years of RN experience in health care or managed care related field. Requires proven record of leading meetings, presenting to groups, ability to build consensus and implement advanced business solutions. Requires thorough familiarity with workflow and process improvement applicable to a healthcare setting, along with prior project management experience.Must possess strong oral, written and interpersonal communication skills to effectively interact with all levels in the organization. Ability to function effectively in a team oriented, fast-paced environment. Position requires proficiency in personal software applications, including word processing, generating spreadsheets, and creating graphics/presentations. Must demonstrate critical thinking skills, problem-solving abilities, effective verbal and written communication, and time management skills to engage clinical and non-clinical audiences. Must have skills to mentor and educate clinical and non-clinical teams to transform health care to a population health model. Requires sound clinical judgment and an understanding of risk adjustment and managed care concepts.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.