**Company :** Highmark Inc. **Job Description :** **Job Description** This job is responsible for leading, optimizing, and transforming all operational aspects of member facing health engagement team activities through case management, disease management, and programs targeted at behavioral health, pharmacy, wellness and social work delivered in the context of a digitally enabled whole-person health model that seeks to establish contextualization and personalization of a dynamic care plan, while enabling efficient access to any combination of co-morbid condition management solutions with seamless omni-channel handoffs. As a key leader of the Medicaid Clinical organization, role is responsible for maximizing and optimizing value of the programs through delivery and as such, is accountable for customer activation, engagement, and experience, quality delivery, health outcomes, care cost management, and operational excellence/administrative cost management. This requires the incumbent to lead their team through the implementation of alternative resourcing strategies and digital transformation of the function. The role is accountable for growing measurable financial and clinical value, both internally within Highmark’s membership population as well as with external provider partners.. This will require close partnership with leaders across the enterprise and direct interactions with senior leaders at clients and providers. This job requires a strategic approach to team development, talent management, and performance optimization, ensuring seamless integration with other departments and a positive impact on member outcomes. **ESSENTIAL RESPONSIBILITIES** + **Lead and manage a large, multi-disciplinary team:** Responsible for delivering and executing member-facing clinical programs which include, fostering a collaborative environment, developing talent, and ensuring the team is equipped to manage case management, transitions of care, and disease management programs. Additionally, this role encompasses managing reporting relationships, hiring and termination decisions, coaching and development, performance management, and staff productivity. It also involves planning, organizing, and directing the day-to-day operations of the department, developing policies and programs, and managing budgets. + **Ensure operational excellence:** Oversee performance review processes, monitor key performance indicators, and deliver expected outcomes in areas like activation, engagement, quality, health, and cost. + **Maintain compliance:** Implement and oversee a comprehensive compliance program for clinical services, ensuring adherence to NCQA standards and all applicable regulations. + **Drive continuous improvement:** Continuously deploy agile best practices, enhance operations based on market intelligence, and connect Population Health clinical programs to support a whole-person health model. + **Providing comprehensive member support:** This includes guiding members through the healthcare system, helping them choose and use their insurance, connecting them with the right tools and resources, increasing engagement in clinical programs, creating targeted campaigns, scheduling appointments, and facilitating medical record transfers. + **Drive strategic alignment and growth:** Partner with Product Management teams to enhance enterprise value through improved clinical outcomes, affordability, and growth. This includes providing business expertise, sharing customer insights, and ensuring alignment with business objectives. + **Operationalize change and innovation:** Lead change management activities related to technical and digital transformation efforts. Deploy engagement best practices, innovate member engagement strategies, and leverage design expertise to optimize customer and clinician experiences. + **Collaborate for seamless integration:** Partner with Customer Experience teams to ensure that the roadmap and design of the customer experience amplifies activation and engagement, and integrates seamlessly with clinical program operations. This includes developing a multi-year roadmap for digital transformation of clinical operations and member engagement capabilities. + **Collaborate across the organization to develop and implement value-driven clinical programs and solutions:** This includes partnering with various teams, including the Government Business Segment, , enGen, , and strategic anchor providers, to create, sell, and deliver products and services that drive incremental enterprise value, improve clinical outcomes, and align with the quintuple aim. + **Drive strategic initiatives and communication:** Lead multiple simultaneous work streams and projects, engage in speaking engagements, and communicate strategic ideas effectively through writing, presentations, and storytelling. **EDUCATION:** + Nursing or Medical degree and/or advanced degree in healthcare administration or related field (e.g., MPH, MHA, MHS, MBA) **Substitutions** : + None **EXPERIENCE:** **Required:** + 8-10 years’ experience in healthcare space (payor, provider, startup) + 3 or more years experience overseeing large scale clinical operations + Deep understanding of rapidly evolving population health and member engagement space + Experience in healthcare value-based care space a plus (e.g., RBE models), especially CM delegation + Familiarity with major health care data sources (claims, clinical) and advanced analytics **Preferred:** + 7 years in management, + 5 years or more experience in healthcare strategy (e.g., tenure in Strategy/Transformation department, Consulting firm) + 2 years or more in a healthcare technology setting (e.g., digital health innovator) **LICENSES or CERTIFICATIONS** **Required** + None **Preferred** + None **Language (Other than English):** None **Travel Requirement:** 0% - 25% **PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS** **Position Type** Office- or Remote-based Teaches / trains others Occasionally Travel from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required No Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely **_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. 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. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy._ _Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._ Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J267795