Provider Improvement Analyst

CareSource; Massachusetts; Hybrid; USD 72,000 - 116,000; Full time

Job summary

CareSource seeks a Provider Engagement Specialist to lead the performance of delegated partnerships and act as engagement lead for high-value health partners. You will manage performance measures, reports, and improvement plans, ensuring compliance with regulatory and NCQA requirements.

You will collaborate with providers and internal teams to drive quality outcomes, support population health initiatives, and contribute to strategic plans.

Qualifications

• Bachelor’s degree in a healthcare related field, or equivalent years of relevant work experience is required.
• Master’s Degree is preferred.
• Minimum of five (5) years of healthcare experience, to include three (3) years of direct work experience in provider relations and/or provider contracting.
• Managed care experience is required.
• NCQA PCMH experience is preferred.

Responsibilities

• Oversee performance measure components, including end-to-end data collection, evaluation, and timely reporting to internal teams and delegated providers.
• Lead identified Market performance and engagement strategic initiatives under supervision.
• Serve as market lead for performance and engagement activities to support network performance, new products, and product expansion.
• Develop understanding of program measures to help delegated providers interpret performance data and meet expectations.
• Collaborate with providers to create and monitor performance improvement plans and ensure accountability for baseline standards.
• Drive quality outcomes through execution and support of Value Based Reimbursement with providers.
• Lead Joint Operating Committees with key health partners and present provider performance data.
• Enhance providers’ population health via outcome and quality improvement techniques.
• Coordinate with Population Health Analytics to exchange clinical information and population data.
• Support strategic plans with leadership and analytics teams.
• Collaborate to develop engagement strategies for individual members.
• Generate monthly and quarterly performance and administrative reports for delegated providers.

Skills

MS Outlook

MS Word

MS Excel

Medicaid/Medicare

Value-based care

Provider relations

Provider contracting

Project management

Communication skills

Time management

Education

Bachelor’s degree in healthcare

Master’s degree preferred

Job description

Job Summary

The Provider Engagement Specialist - Provider Delegation Performance is responsible for overseeing and improving the performance of delegated partnerships programs and act as the engagement lead for high value, strategic health partners.

Essential Functions

• Assume full management responsibility for all performance measure components, including end-to-end data collection, evaluation, and timely dissemination of reports to both internal teams and delegated providers.
• Lead for identified Market performance and engagement strategic initiatives under the direct supervision of their manager
• Market lead for performance and engagement activities to support overall network performance, new products, and product expansion
• Develop a deep understanding of all program measures and metrics to support delegated providers in interpreting performance data and meeting expectations.
• Collaborate with providers individually to create and monitor performance improvement plans, engaging internal subject matter experts as needed and ensuring accountability for baseline performance standards.
• Knowledgeable of federal and state laws and regulations pertaining to provider contracting
• Drive quality outcomes through execution and support of Value Based Reimbursement agreements with providers
• Assume leadership role in JOC’s (Joint Operating Committees) with key health partners and be able to develop and present data on Provider performance
• Enhance effectiveness of Providers’ population health through a variety of member health outcome and quality improvement techniques
• Collaborate with Population Health Analytics team in coordinating the exchange of clinical information and member/population level data
• Assist in development and implementation of strategic plans in collaboration with leadership and population health analytics team
• Collaborate with the Provider to develop and enhance the practice’s engagement strategies for individual members
• Generate monthly and quarterly performance and administrative reports, ensuring consistency, accuracy, and timely distribution to delegated providers. This includes reporting related to contracts, regulatory, NCQA and other requirements.
• Develop a deep understanding of all program measures and metrics to support delegated providers in interpreting performance data and meeting expectations.
• Provide on-site practice transformation support and education to Providers identified as partners in the CareSource PCMH program. CareSource supports the NCQA Patient Centered Medical Home model.
• Works with leadership and stakeholders to evaluate policy and process changes for potential provider impacts, monitors implementation of key initiatives, and provides leadership on initiatives affecting providers
• Ensures CareSource complies with regulatory requirements, addresses compliance concerns, achieves accreditation standards, and participates in market audits
• Perform any other job duties as requested

Education And Experience

• Bachelor’s degree in a healthcare related field, or equivalent years of relevant work experience is required
• Master’s Degree is preferred
• Minimum of five (5) years of healthcare experience, to include three 3 years of direct work experience in provider relations and/or provider contracting
• Managed care experience is required
• NCQA PCMH experience is preferred

Competencies, Knowledge And Skills

• Intermediate proficiency level with Microsoft Outlook Word, and Excel
• Experience with Medicaid and Medicare products and programs
• Value-based program oversight and performance tracking
• Experience working within FQHCs, Health and Human services providers or equivalent
• Knowledge of Provider Network Management Processes & Services
• Proven experience in program management and performance monitoring initiatives or relevant position
• Working knowledge of project/program management practices
• Ability to manage and prioritize multiple tasks, promote teamwork and fact-based decision making
• Strong negotiation skills
• Effective oral and written communication skills
• Critical listening and thinking skills
• Training/teaching skills
• Time management skills

Licensure And Certification

• Employment in this position is conditional pending successful clearance of a driver’s license record check. If the driver’s license record results are unacceptable, the offer will be withdrawn or, if you have started employment in this position, your employment in this position will be terminated
• To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position. CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 – March 31) as a condition of continued employment. Employees hired during Influenza season will have thirty (30) days from their hire date to complete the required vaccination and have record of immunization verified.
• CareSource adheres to all federal, state, and local regulations. CareSource provides reasonable accommodations to qualified individuals with disabilities or medical conditions, sincerely held religious beliefs, or as required by state law to enable the employee to perform the essential functions of the position. Request for accommodations will be completed through an interactive review process.
• Six Sigma Certification or Project Management certification preferred

Working Conditions

• Mobile Worker: This is a mobile position, meaning that regular travel to different work locations is essential. Will be exposed to weather conditions typical of the location and may be required to stand and/or sit for long periods of time.
• Reside in the same territory they are assigned to work in; exceptions may be considered, due to business need
• May be required to travel greater than 50% of time to perform work duties. A valid driver’s license, car, and insurance are necessary for work related travel
• Required to use general office equipment such as a telephone, photocopier, fax machine, and personal computer
• Flexible hours, including possible evenings and/or weekends as needed to represent CareSource

$72,200.00 - $115,500.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Salary

Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.