Manager Decision Support Analytics

JOB SUMMARY

Highmark Health is seeking an experienced and highly analytical Manager, Decision Support Analytics to lead a critical team responsible for our ACA (Affordable Care Act) Risk Adjustment analytics and CMS EDGE server data submissions.

This pivotal role requires a dynamic leader with a proven track record in healthcare operations and data analytics, particularly skilled in designing streamlined processes with robust controls and comprehensive reporting. The successful candidate will directly manage a team of 3 actuaries and 2 decision support analysts.

We are looking for a visionary manager with a deep understanding of the ACA risk adjustment landscape and demonstrated expertise in CMS EDGE server operations. If you are passionate about leveraging data to drive compliance, financial accuracy, and operational efficiency within a complex healthcare environment, we encourage you to apply.

ESSENTIAL RESPONSIBILITIES

• Performs management responsibilities to include, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Plan, organize, staff, direct and control the day-to-day operations of the department.
• Develop and implement policies and programs as necessary.
• May have budgetary responsibility and authority.
• Serve as the decision support analytics subject matter expert in the development and implementation of dashboards and reports to support key clinical and operational initiatives.
• Maintain key relationships with leadership and other stakeholders to proactively identify and communicate performance and continuous improvement opportunities for quality improvement and clinical effectiveness.
• Oversee the ongoing sourcing, assessment, defining, and maintenance of business data to ensure integrity, quality, validity, and overall applicability to the identification, analysis, and interpretation of ongoing trends or patterns in complex data sets for specified projects.
• Provide guidance on opportunities to enhance analytic capabilities with a particular focus on the ability to measure, benchmark and track value metrics.
• Lead the design, implementation, and maintenance of analytical processes and reports supporting Gateway Health Plan’s performance (internal to the organization and in comparison to industry benchmarks/best practices).
• Manage the utilization of measurement tools, statistical methods and benchmark comparisons to determine and analyze outcome measures in support of organizational goals.
• Partner with leadership and process owners to define key metrics and analytic needs for implementation, including dashboards, scorecards, and overall reporting solutions.
• Implement special initiatives to support the reporting and analytics needs of the organization as directed.
• Other duties as assigned or requested.

PREFERRED RESPONSIBILITIES

•    Driving strategic oversight of ACA risk adjustment analytics, ensuring accurate risk score evaluations and impactful financial projections.
•    Leading and optimizing the end-to-end CMS EDGE server data submission process, from data validation and reconciliation to error resolution and timely, compliant submissions.
•    Implementing and maintaining stringent operational controls and audit-ready reporting mechanisms for all risk adjustment and EDGE server activities, strategically partnering with IT to enhance our data submission pipelines.
 

EDUCATION
Minimum

• Bachelor's Degree in Clinical-related field, Business Administration, Healthcare Administration, Health Information Management, or related discipline, or relevant experience and/or education as determined by the company in lieu of bachelor's degree

Preferred

• Bachelor's Degree - Clinical-related field, Business Administration, Healthcare Administration, Health Information Management, or related field

EXPERIENCE

Minimum

• 5 years of progressive experience in a clinical or reporting and analysis field in a healthcare organization
• Prior leadership and/or project management experience

Preferred

• Experience in a clinical area/function/organization

LICENSES & CERTIFICATIONS

Minimum

• None

Preferred

• None

SKILLS

• Advanced knowledge of SAS and SQL required
• Advanced computer skills with a strong knowledge of spreadsheet programs required
• Ability to perform under stressful and changing circumstances and deadlines; effective written and oral communication skills; and strong problem solving, project management, teamwork, and organizational skills required
• The ability to assist in ensuring compliance with regulatory agencies and HIPAA regulations required

LANGUAGE REQUIREMENT (other than English)?  
None

TRAVEL REQUIREMENT:
0% - 25%

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
 

Position Type:

Office-Based

Office-Based Positions

An employee in this position works in an office environment.  The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Teaches/Trains others regularly

Frequently

Travels regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (Sales employees)

Does Not Apply

Physical Work Site Required

Yes

Lifting: up to 10 pounds

Does Not Apply

Lifting: 10 to 25 pounds

Does Not Apply

Lifting: 25 to 50 pounds

Does Not Apply

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 position 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. 

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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.

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