At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.
When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.
Let's build healthier communities together, join now!
JOB SUMMARY
Strategic leader responsible for designing, implementing, and scaling the value-based transformation strategy across Specialty Practices. The Director serves as a strategic partner to providers, translating performance data and value-based contract objectives into actionable practice transformation initiatives that improve quality, total cost of care, patient outcomes, provider experience, and financial performance.
ESSENTIAL FUNCTIONS
- Establish the operating model, methodology, standards, and performance framework in alignment with organizational priorities and value-based contract objectives.
- Establish a trusted-advisor relationship with physicians and practice leadership creating a provider-centric transformation experience based on transparency, collaboration, and shared accountability.
- Lead interventions addressing clinical workflows, access and capacity, care coordination, referral management, patient engagement, documentation and coding, risk adjustment, revenue cycle, HER optimization and office staff capabilities.
- Develop and oversee provider performance management using: HEDIS, STAR Ratings, CMS measures, Risk Adjustment / RAF, Total Cost of Care, PMPM, Utilization, Readmissions, ED utilization, Medication adherence, Patient experience & Provider experience.
- Establish provider segmentation and differentiated intervention strategies based on performance and opportunity.
- Partner with Medical Management, Analytics, Finance, Pharmacy, and providers to identify opportunities involving: avoidable admissions, emergency department utilization, readmissions, high-cost members, imaging utilization, procedure variation, site-of-care optimization, referral leakage, centers of excellence, specialty pharmacy & therapy optimization
- Partner with Pharmacy and clinical teams to identify opportunities related to: Specialty drug utilization, Biosimilars, Formulary adherence, Medication adherence, Infusion site optimization, Prior authorization, Appropriate therapy utilization & Cost-effective alternatives.
- Partner with Contracting and Finance to translate contract requirements into provider action plans, monitor incentive performance, support provider understanding of value-based economics, identify opportunities for shared savings, evaluate performance against quality and cost targets, support provider readiness for new value-based arrangements & connect transformation activities to financial outcomes.
- Establish the operating standards for Value-Based Transformation Consultants, including: provider assignment, visit methodology, practice assessment, performance review, intervention planning, resource coordination, escalation, follow-up & documentation
- Create an integrated resource model connecting providers with: Medical Directors, Quality, Population Health, Care Management, Pharmacy, Network Management, Provider Relations, Practice Management, Risk Adjustment, Coding/CDI, Analytics, Finance, IT/Digital & Compliance.
EDUCATION
- Master's Degree in Public Health or Health Services Administration
- Bachelor's Degree in Public Health or Health Services Administration
EXPERIENCE
Master’s degree, preferred, in a healthcare-related field such as Master of Public Health or Master of Health Administration. Or, bachelor’s degree in a healthcare-related or analytical field such as: Public Health, Health Administration, Nursing, Pharmacy, Health Sciences, Business Administration (with healthcare experience), Economics or Data Analytics (with healthcare exposure).
LICENSES AND CERTIFICATIONS
- None required
COMPETENCIES
- Customer Delight
- Financial & Business Acumen
- One Company Mindset
- Practical Knowledge in Tech
- Data Driven Insights
It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.
Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.
We encourage Veterans and Disabled to Apply.