Medicare Advantage Quality Consultant

Apply for Medicare Advantage Quality Consultant | Careers at Highmark Health Skip to main content Careers Working here Our Companies Career Areas Early CareersInterns Talent Community Team Member Stories Veterans Explore Jobs Provider ServicesMedicare Advantage Quality Consultant Explore our jobs Medicare Advantage Quality Consultant Apply Open in new tab iconBuffalo NY 1 Seneca St Ste 3400Company Highmark Inc.Job Description JOB SUMMARY This job is directly responsible for the value creation impact and cost control and fiscalROI targets as set by the Organization including revenue stream outcomes and engagement of primary care providers PCP enrolled in government value-based reimbursement programs and continuous improvement models. This job is a highly skilled subject matter expert SME in Medicare STARS Medicaid HEDIS and risk revenue streams and provides strategic hands-on office based support to PCPs for analysis of performance Medicare STARS Medicaid HEDIS and risk revenue streams identifies opportunities for improvement in value creation cost control and utilization performance and develops strategic plans in collaboration with PCPs and the inter-departmental teams for transformation of workflows resulting in outstanding performance in government programs ensuring that ROI targets set by the Organization are met or exceeded. Further in a matrix management environment the Medicare Advantage Quality Consultant is responsible for collaborative work with other functions in the provider area data analytics and key internalexternal stake holders to provide the most appropriate support to the PCPs based upon data analysis and dashboard reports.This is a hybrid based role based in Buffalo New York - Onsite T W Th. ESSENTIAL RESPONSIBILITIESDirectly 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 ROIfiscal 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 Organizations value-based programs for both the commercial and government business ACA Medicare STARS Medicaid HEDIS risk revenue.Function as the Organizations 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 Highmarks value-based reimbursement programs to lend support as neededdefined 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.EDUCATIONRequiredBachelors Degree in a clinical or healthcare related fieldSubstitutions6 years of relevant experience in lieu of a Bachelors DegreePreferredMasters Degree in a clinical or healthcare related fieldLICENSES OR CERTIFICATIONSRequiredNonePreferredNoneEXPERIENCERequired5 years in MedicareMedicaid 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 care3 years in data analysis interpretation and outcomes strategic plan developmentExperience with Medicare STARS Medicaid HEDIS risk revenue value streams and population health managementPreferred7 years in a government program setting managed care primary care management or other clinical settingExperience in Lean Six Sigma TQI TQC or other quality management certificationExperience in health plan provider network performance management population health management continuous improvement or provider engagement modelsSKILLSMust be able to effectively resolve issues and problems across all areas of the corporation by understanding corporate strategies policy and scope of authorityBecause of the broad impact of decisions that are made must be knowledgeable and sensitive to many internal and external corporate issuesAptitude for a high visibility position demanding integrity uncompromising professionalism diplomacy and conflict managementDemonstrates 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 relationshipsSuperior written and verbal communication skills and listening skillsAbility to adapt engagement strategies to meet market needsTravel Requirement50 - 75Language Requirement other than EnglishNonePHYSICAL MENTAL DEMANDS AND WORKING CONDITIONSPosition TypeOffice-BasedTeachesTrains others regularly ConstantlyTravels regularly from the office to various work sites or from site-to-siteFrequentlyWorks primarily out-of-the office selling productsservices Sales employeesDoes Not ApplyPhysical Work Site Required NoLifting up to 10 pounds ConstantlyLifting 10 to 25 pounds RarelyLifting 25 to 50 pounds RarelyDisclaimer 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 Companys Handbook of Privacy Policies and Practices and Information Security Policy.Furthermore it is every employees responsibility to comply with the companys 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 Minimum67500.00Pay Range Maximum126000.00Base pay is determined by a variety of factors including a candidates 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.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 HRServiceshighmarkhealth.orgCalifornia Consumer Privacy Act Employees Contractors and Applicants Notice Apply Job DetailsJob categoryProvider ServicesPosition TypeFull TimePosted2025-11-06T162603.0874970000LocationsBuffalo NY 1 Seneca St Ste 3400Line of BusinessEntityRecruiterHiring ManagerExperience LevelReq IDJ272326 Share Facebook X LinkedIn Whatsapp Email Copy URL Apply Open in new tab iconArrow left iconTwitter iconFacebook iconLinkedin iconInstagram iconYoutube iconGlassdoor icon Featured Links Competitively Sensitive Information Cyber Security Notice at Collection E-Verify English E-Verify - Employee Rights and Responsibilities Data Protection Sitemap Terms of Service Do Not SellShare E-Verify Spanish Digital Privacy Policy Highmark Health is an independent licensee of the Blue Cross Blue Shield Association. 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 HRServiceshighmarkhealth.org. © 2025 Highmark Health. All Rights Reserved.