Community-Based Health Services Reimbursement Consultant

Job Description

Overview

Global Communities is a $250M non-profit organization that has been in operation for over 70 years. Global Communities works at the intersection of humanitarian assistance, sustainable development, and financial inclusion to save lives, advance equity, and secure strong futures. The organization has a small but growing US Programs portfolio comprised predominantly of community health work. As we strive to leverage our technical expertise and knowledge of local communities, the organization is seeking to explore alternative business models such as health services reimbursement to grow our impact in target markets.

Responsibilities

Our organization is seeking a consultant to develop an effective reimbursement model for community-based health programming, including community health workers (CHWs), doulas, and other non-medical care providers that is tailored to or can be incorporated with our organizational structure(s). The consultant should have in-depth knowledge and experience in healthcare reimbursement (both private and public/Medicaid) with an understanding of the California market a plus, and a comprehensive understanding of public/community health, particularly the work of CHWs. The objective is for the consultant to determine strategies that will drive improvements in health for Global Communities’ target populations and generate sustainable revenue for the organization, identify and evaluate opportunities across the reimbursement landscape (such as Medicaid/Medi-Cal or managed care plans), and develop a business plan for funding the initiative, including outlining the operational model and crafting concept notes or proposals.

The consultant will be required to perform the following tasks:

• Health Services Reimbursement Model Development:
  • Carry out an analysis of current reimbursement models for community-based health programming by Medicaid/Medi-Cal and/or managed care providers in the domestic context.
  • Develop an innovative and effective reimbursement model, including financial projections and rates, tailored to Global Communities’ current needs and realities as well as desired program growth areas.
  • Identify rules, regulations, and compliance considerations associated with the model.
  • Consult with stakeholders, including staff, CHWs, and insurance representatives, to understand their needs and incorporate feedback into the model.
  • Document lessons learned about reimbursement rates.
• Business Plan Creation:
  • Prepare a comprehensive business plan, detailing how the organization can implement the developed health services reimbursement model.
  • Include information about the necessary resources, potential risks, and a timeline for implementation taking into consideration the evolving context of California’s Department of Healthcare Services’ and private insurance companies’ reimbursement programs.
  • Identify cost-allocation strategies and protocols to ensure that reimbursement funds can be “braided” with grant funds without concerns of duplication.
• Pathways and Opportunities Identification:
  • Identify potential pathways (starting in Southern California) where the proposed reimbursement model can be applied or tested.
  • Coordinate with staff to design how potential funding opportunities can fit both within existing programs and/or by expanding programming implementation.
  • Use evidence-based approaches to identify these opportunities, incorporating a deep understanding of the public/community health sector and the work of CHWs and doulas.
• Proposal Development:
  • Develop concept notes or proposals for identified opportunities, highlighting their potential impact and feasibility.
  • Identify potential funding sources and develop strategies for approaching them effectively.
• Stakeholder Engagement:
  • Facilitate regular communication with relevant stakeholders, ensuring their feedback is incorporated into the model and business plan.

Approach

The consultant will work with our US Programs team and US Growth Advisory Group to manage the consultancy and expected results. They will work closely with our team to gain a thorough understanding of our organization’s vision, mission, and strategic plan. The consultant will seek to understand our current US program portfolio and community health work in the Southern California market in addition to our US Growth plan for program expansion and impact.

Deliverables

The consultant will deliver the following to Global Communities:

• A comprehensive analysis of current and potential reimbursement models for community-based health services.
• A health services reimbursement model tailored for our organization.
• A detailed business plan with cost-allocation strategies for implementing the proposed model.
• A list of potential funding opportunities for implementing or testing the proposed model.
• Detailed concept notes or proposals for each identified opportunity.
• A stakeholder engagement report detailing feedback and how it was incorporated.
• A proposed timetable for steps required to build and pilot the model.

Timeline

The engagement will begin in agreement between Global Communities and the selected consultant; and is expected to be completed within 5 months. Detailed timelines for each phase will be agreed upon the commencement of the project and more detailed work plan will be reviewed and approved.

Budget and Payment Terms

The consultant and Global Communities will negotiate a daily rate for services rendered. Additional travel and representation costs will be budgeted by the consultant and approved by Global Communities monthly. Payment terms will be detailed in the consultancy agreement.

Reporting

The day-to-day engagement and coordination will be managed by the US Growth Advisory Group project director. The consultant will provide regular updates on the progress of work plan activities.

Qualifications

Experience and qualifications

It is expected that the consultant will demonstrate the following qualifications and demonstrated experience:

Education:

• An undergraduate degree in Public Health, Health Economics, Health Administration, Business Administration, or a related field.

Experience:

• Minimum of 5 years of experience in healthcare reimbursement, preferably within a healthcare setting or insurance company.
• Proven track record in navigating reimbursement options with the California Department of Healthcare Services or managed care plans and understanding evolving reimbursement models.
• Experience working with health, social, or community organizations and familiarity with their operational modalities.
• Previous experience working with or understanding the role of community health workers and doulas.
• Demonstrated experience in strategic planning, business plan development, and proposal writing.
• Preferred experience with securing funding for health-related projects, preferably related to health services reimbursement.
• Familiarity with combining funding from different sources to achieve programming goals

Skills:

• Excellent analytical skills, with the ability to interpret complex health and financial data.
• Strong written and verbal communication skills, with experience in facilitating stakeholder engagement processes.
• Exceptional proposal writing and presentation skills.
• Proficiency in project management, including planning, organizing, and coordinating tasks.
• Knowledge of current trends, best practices, and legal aspects of healthcare reimbursement.

Personal Attributes:

• Strong interpersonal skills, with the ability to work effectively with a diverse range of stakeholders.
• Creative mindset and vision for building something new.
• Demonstrated ability to work independently, as well as part of a team.
• Highly motivated and committed to achieving the objectives of the consultancy.
• Flexibility and adaptability to accommodate changes in project direction.

Other Requirements:

• Availability to travel, if necessary, to meet with stakeholders or to gain a better understanding of the organization’s operations and the work of community health workers.
• Evidence of previous work such as past project reports, proposals, business plans, and references from previous clients

About the Organization

As an organization working to advance public health, Global Communities has an obligation to model best practices and to do all we can to protect each other, our partners and the communities where we work. To ensure the continuity and effectiveness of our business operations, Global Communities is adopting a policy to safeguard the health of our visitors, employees, families, and the larger global community from COVID-19. Effective January 3, 2022, all U.S.-based Global Communities employees are required to provide proof of having received full dosage of COVID-19 vaccine that is FDA approved, approved for emergency use authorization, or have an approved medical or religious exemption on file with Global Communities, as a condition of employment.

Global Communities holds strict safeguarding principles and has a zero-tolerance policy for conduct of sexual exploitation, abuse, and harassment. In the process of recruitment, selection, and appointment, Global Communities will conduct robust reference and background screening checks, including international vetting as a signature of the Global Misconduct Disclosure Scheme to ensure children and vulnerable adults are safeguarded, and abuse is prevented. The incumbent is required to carry out their duties in accordance with Global Communities Safeguarding policy and the Standards of Conduct.

Global Communities is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment, without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.