Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Population Health Transformation Lead is a data-driven leader responsible for translating affordability, efficiency, and quality outcome performance goals into integrated clinical improvement plans across Capital’s Provider Network. The Transformation Lead is primarily focused on Capital’s Medicare Advantage (MA) Lines of Business, with responsibility to craft and curate network clinical strategies that align with business needs. The Lead role will serve as a translator, who can speak both the language of Plan performance and Provider clinical operations transformation. This role is expected to coach both internal and external stakeholders on data interpretation and match evidence-based clinical strategies to drive clinical improvement across care access, cost, utilization, quality and other priority outcomes.

• Lead clinical oversight for MA provider performance responsible for surveilling performance trends, translating clinical insights, and partnering across Capital’s Network teams to maintain provider-specific clinical priorities and improvement roadmaps.
• Responsible for integrating Plan and Provider clinical strategies and operations processes to minimize duplication and maximize synergies and clinical collaborations.
• Partners across Population Health, Government Programs and Provider Network leaders to evaluate the efficacy of existing MA clinical programs, and design clinical and operational strategies to optimize performance.
• Clinical lead for market-facing representation to the provider network. Engage value-based care partners to enhance performance outcomes; leading, designing and driving scalable practice & provider engagement for MA STARS, TCOC & Risk programs.
• Thought leader influencing Medicare TCOC and affordability strategies, including utilization management (UM) trend control and UM process improvement initiatives. Assist in review and implementation of UM and medical policy, including recommendations for improvements to enhance efficiency, quality and effectiveness.
• Integrate pharmacy and medical care strategies, acting as a bridge partner with Capital’s pharmacy benefits manager and serving as consultant on MA benefits design.
• Leverage existing analytics tools and assist in enhancing data products as critical infrastructure to design new clinical strategies and manage the performance of existing clinical programs.
• Work in collaboration with UM and Care Management (CM) to understand utilization trends and develop programs to address inappropriate utilization, readmissions and achieve MLR targets. Leads improvement of high-cost claimant clinical operations in collaboration with network providers.
• Clinical committee oversight including functions such as member safety and strategic partner Joint Operating Committees.
• Data-driven leadership aligns CMS compliant MA strategies to mitigate regulatory compliance risk while tracking and driving progress towards Capital’s annual goals.
• As needed, documents in medical management systems to memorialize clinical review, plan of care and coverage decisions. Works with network provider partners to access and use electronic health records as needs dictate.
• Support Chief Medical Officer, Vice President of Population Health and Government Programs stakeholders with other duties as assigned.

Skills:

• Outcome oriented, excellent cross-functional leadership and communication skills.
• Quality-first mentality with working knowledge of healthcare operations.
• Demonstrated healthcare improvement and change management success.
• Strong data orientation, with basic self-serve analytics capabilities.
• Leads and manages effective meetings, builds trust and rapport across teams

Knowledge:

• Familiar with the Medicare policies & practices promulgated by CMS that impact members, provider networks, and managed care organizations.
• Deep understanding of healthcare strategy and interconnected payer/ provider care ecosystems.
• Deep understanding of and appreciation for the rapid health-tech evolution, including digital health solutions and the incorporation of Artificial Intelligence (AI) across clinical care & operations.
• Knowledge of Health Plan operations related to both Commercial and Medicare LOB.

Experience:

• Minimum 8 years’ leadership experience in a Managed Care/Health Plan, Medicare program, ACO or large Health Care Provider Organization, with experience in clinical operations quality, and program design.
• 3+ years of full-time experience applying clinical guidelines and evidence-based care to assess and influence the practice patterns and population outcomes attributable to a provider practice or group(s).

Education and Certifications:

• Master’s Degree

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.

Location:

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays.

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.    
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.