Highmark · 7 hours ago
Medicare Advantage Quality Consultant - Central, PA
Blue Bell, PA
Full-time
Hybrid
Senior Level
5+ years expHighmark Inc. is a healthcare company focused on improving health outcomes through innovative solutions. The Medicare Advantage Quality Consultant is responsible for providing strategic support to primary care providers enrolled in government value-based reimbursement programs, focusing on data analysis and performance improvement to meet organizational ROI targets.
Health CareHealth InsuranceInsuranceWellness
Responsibilities
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 Medicare Advantage Quality Consultant 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 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
Qualification
Required
Bachelor's Degree in a clinical or healthcare related field
6 years of relevant experience in lieu of a Bachelor's Degree
5 years 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 in data analysis, interpretation, and outcomes strategic plan development
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
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
Preferred
Master's Degree in a clinical or healthcare related field
7 years 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
Company
Highmark
Highmark provides health insurance plans for individuals and businesses.
10001+ employees
H1B Sponsorship
Highmark has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (11)
2024 (7)
2023 (19)
2022 (21)
2021 (18)
2020 (23)
Funding
Current Stage
Late StageTotal Funding
$27.3M2018-04-06Grant· $25M
2014-08-07Grant· $2.3M
Leadership Team
Deborah Rice-Johnson
CEO, Diversified Businesses at Highmark Inc. and Chief Growth Officer
Paul Sikora
CTO Provider Services
Recent News
2025-12-11
Company data provided by crunchbase