Martin's Point Health Care

• Provide clinical leadership across utilization management, care management, population health, quality, pharmacy, medical policy, payment policy, and clinical program development • Partner with Health Plan senior leadership to advance clinical outcomes, affordability goals, growth targets, and overall health plan strategy • Lead cross-functional collaboration among Medical Directors, Medical Economics, Quality, Network, Compliance, Pharmacy, Operations, and Clinical Programs • Support compliance with government program requirements, including clinical appeals and grievances, using sound clinical evidence and medical judgment • Use clinical, quality, utilization, and financial data to identify trends, assess performance, and recommend actionable interventions • Develop strategies to improve medical expense management, appropriate utilization, quality of care, and population health outcomes • Provide clinical input into product design, Medicare bids, risk adjustment, STARS, HEDIS, value-based arrangements, and clinical integration initiatives • Communicate complex clinical, regulatory, and operational information clearly to executive, provider, clinical, and non-clinical audiences • Support appropriate utilization of services through strong partnership with Utilization Management, Care Management, and physician leaders • Represent the organization with regulatory entities, professional societies, providers, network partners, and external stakeholders, as appropriate • Build and strengthen relationships with hospitals, physicians, and other health care providers to support network engagement and performance goals • Support strategies tied to population health, care management, provider performance, and contractual outcomes • Lead, support, and develop physician leaders and clinical team members, as assigned

• Ensure a smooth workflow of all projects across the Marketing department • Maintain, optimize, and improve upon internal processes • Partner with various teams and external vendors for project support • Maintain the traffic project management system • Monitor team capacity and balance workloads • Perform final quality reviews prior to production release • Manage daily deliverables and keep records of active and completed projects • Partner with Compliance to ensure regulatory requirements are met • Contribute to production status meetings with accurate updates

• Performs clinical chart reviews and audits to ensure accuracy and compliance with HEDIS measures. • Develops reports to identify HEDIS care gaps and trends and works closely with providers to ensure the necessary services are provided and documented according to HEDIS requirements. • Assists in the coordination of outreach efforts to request, collect, and secure clinical documentation from individual providers or provider groups as indicated by individual HEDIS measure specifications. • Collaborates with health plan departments to identify HEDIS data sources and develop systems to capture this data in accordance with HEDIS technical specifications, such as supplemental databases. • Collaborates with data analysts and quality teams to support performance improvement. • Documents findings and recommends strategies to improve HEDIS measure performance. • Applies clinical expertise to identify and validate data discrepancies. • Educates non-clinical staff on HEDIS requirements and clinical relevance of data. • Corresponds with members and clinical providers to effectively coordinate care, obtain medical records, and ensure patients receive preventive and chronic disease management services.

• Handles high level contracting and renegotiations with large and strategic provider groups, and PHO’s • Leads the contracting effort for opening new expansion markets • Conducts high level provider education in-services • Develops PowerPoints for provider education trainings • Attends Quarterly Health Plan Sales meetings, submits monthly recruitment reports • Works closely with the Senior Network Operations Specialist and Senior Credentialing Specialist

• Manage the Health Plan Medical Directors • Provide clinical support for the Health Management Utilization Management, Care Management and Quality teams • Drive the development, promotion and delivery of high quality, evidence-based utilization and care management programs and processes • Lead programs and reviews to support effective medical expense management, medical quality programs and outcomes, and programs to manage medical utilization trends such as inpatient, Emergency Department, Site of Care, pharmacy and radiology • Achieves defined clinical outcomes, affordability goals and growth targets • Works closely across the HP to ensure compliance with government program regulations, including management of clinical appeals and grievances with sound clinical evidence and advice • Works closely with the Medical Directors and the Director of Medical Economics to devise analytic approaches that support and measure strategic development and sound clinical programs • Provides clinical insight into data to assist in development of and measurement of tailored interventions that address clinical trends and opportunities • Develops key strategies to address opportunities in medical expense management • Identifies opportunities for improvement in the quality of care that create competitive advantage for Martin’s Point as it relates to the health of populations served • Accountable for appropriate Utilization Management processes • Assists and provides clinical input into the evolution of care/utilization management, quality, and pharmacy related programs • Contributes to and advises in product design and the Medicare bid processes • Contributes to and advises in areas of clinical integration as it relates to risk adjustment • Serves as a central HP leader aligning medical, clinical, and operational functions to achieve seamless and thorough solutions related to Medical and Payment Policies • Actively engages with quality, network, and compliance teams to help drive performance

• Provide support to the operations team including HRIS, benefits, and payroll • Ensure the accuracy of HR data within the HR systems • Coordinate with HRIS team for regulatory and compliance reporting data • Support ongoing HRIS functionality enhancements and level I system troubleshooting • Provide administrative support for HR system processes • Provide routine HR data and reports as needed • Execute day-to-day HR operations tasks ensuring compliance • Develop standard reports, ad hoc reporting for HR • Coordinate data for regulatory reporting such as EEO-1, VETS-4212, AAP, etc. • Provide level I support on general HR system inquiries and troubleshooting • Collaborate with stakeholders to support HR projects

• The Senior Financial Business Partner performs in-depth analyses of organizational financial performance measures and statistical data related to many aspects of the business. • Responsible for data collection, analysis, reconciliation, review/evaluation and reporting in appropriate formats detailed financial analyses of various operational activities. • Responsible for the timely and accurate identification and analysis of projects based on current and strategic business needs. • Participate in monthly accounting closing activities, facilitates provider compensation, team projects, departmental budget support and analysis, various special analytical assignments and other tasks as assigned. • Interact with staff, management and senior leadership, other departments, external organizations, and other members of the Finance Department on a regular basis.

• Building and maintaining data pipelines and infrastructure to support organizational requests. • Working closely with other data professionals with IT Data & Analytics as well as business users to ensure data is reliable and accurate. • Implementing data pipeline integrations, while adhering to security, quality and data transformation standards. • Designing and maintaining ETL pipelines for ingesting and transformation data into database storage adhering to specification files. • Integrating data from multiple different sources to create single-source data sets. • Optimizing data pipelines for performance and scalability with a focus on cost savings. • Implementing quality control processes around pipelines to ensure accuracy, reliability and consistency with a focus on data validation. • Documenting all data pipeline creation to promote knowledge sharing across teams and business owners. • Troubleshooting pipeline failures, missing data files and data quality issues.

• Leads the migration of legacy reporting platforms to Power BI • Designs and implements robust semantic models and data sets for self-service analytics • Establishes and enforces Power BI governance standards • Partners with data engineering teams for optimized data pipelines • Collaborates with stakeholders to define KPIs and reporting requirements • Mentors junior analysts in DAX and data modeling • Monitors and optimizes Power BI performance • Supports change management and user adoption through training

• The Salesforce Developer works directly with the larger Salesforce teams to implement new and existing business processes that lend themselves to a Salesforce solution. • Responsible for evaluating User Stories and identifying the best way to implement the business needs within the Salesforce platform, through configuration, declarative development, and custom code. • Uses their experience and Salesforce knowledge to recommend the best practice solutions, with a preference for out of the box Salesforce features, but capable of custom code development when that approach is necessary. • Responsible for the development, testing, and implementation of the custom code solution. • Able to translate User Stories into Automated Tests that validate business needs. • Support and collaborate with the larger Salesforce Team on Salesforce initiatives and projects.