Clinical Transformation Partner RN; Remote

Company :

Highmark Health

JOB SUMMARY

This job works directly with network providers to support key clinical transformation programs with a focus on utilization of appropriate care. The team member works with internal and external stakeholders to ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. The team member will also work with providers to identify specific areas of improvement within the same domain and help providers develop meaningful action plans to improve performance.

The team member is responsible for building relationships, engaging clinicians, educating on Utilization Management policies and processes, developing workflows and resources, and improving provider performance.

• Review provider performance according to accepted and established criteria, as well as other approved guidelines and medical policies.
• Analyze qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction.
• Educate providers and other relevant external stakeholders on medical policy clinical criteria used to authorize care on a proactive basis.
• Develop and sustain positive working relationships with internal and external customers.
• Respond to customer inquiries and offer interventions and/or alternatives.
• Other duties as assigned or requested.

• 5 years experience in any of the following healthcare areas: the provider environment (hospital, facility, PCP, specialist, supporting area(s)), or healthcare insurance industry, or healthcare administration in a provider office, hospital and/or health systems, or healthcare consulting in provider setting.
• 3 years of experience in utilization management/care management/QA/managed care.

• 3 years of experience in data analysis, interpretation, and outcomes strategic plan development.
• 1 year of lean, six sigma, TQI, TQC or other quality and/or project management certification.

• Ability to analyze data, measure outcomes, and develop action plans.
• Working knowledge of pertinent regulatory and compliance guidelines and medical policies.
• Ability to multitask and perform in a fast‑paced and often intense environment that requires flexibility.
• Excellent written and verbal presentation skills, excellent interpersonal and negotiation skills, and ability to positively influence others. Engages with external stakeholders with a professional demeanor and customer‑centered mindset.
• Be a team player who possesses strong analytical and organizational skills.

• Bachelor’s degree in nursing OR licensed RN with associate's degree or RN diploma.

• None

• Current State of PA RN licensure OR Current multi‑state licensure through the enhanced Nurse Licensure Compact (eNLC).

• PA Driver's license
• Certification in nursing area of expertise

None

0% - 25%

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:
Yes

Lifting: up to 10 pounds:
Constantly

Lifting: 10 to 25 pounds:
Occasionally

Lifting: 25 to 50 pounds:
Rarely

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.

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…