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RN- Clinical Provider Consultant - 004039

Company: Excellus BlueCross BlueShield
Location: Utica
Posted on: April 16, 2019

Job Description:

Under management guidance, this position in conjunction with the Provider Performance Improvement Consultant develops, supports, executes, and facilitates highly visible strategic provider quality improvement, cost and use management programs and partnerships that improve the effectiveness, efficiency, quality, and safety of office-based physician and hospital care. The incumbent aims to improve the quality care and safety of patients and populations through improvements in systems and processes of care. Working as a change agent, engages with and coaches physician practice CEOs, hospital CMOs, COOs, physicians, practice administrators, quality leadership, nurse care managers and others to facilitate quality improvement and transformation in physician practices and hospitals. This position serves as a consultant and subject matter expert in all aspects of clinical cost and quality improvement and practice redesign. Researches, analyzes, and interprets specific physician, practice, and/or hospital data; identifies opportunities for improvement and recommends appropriate interventions, coaches and facilitates implementation, and provides ongoing reporting and evaluation. Prepares and presents outcome reports on program activities and performance to internal and external stakeholders, as well as to local, regional, and national audiences as needed. This is an external facing role that requires travel to our provider and physician offices.The ideal candidate will have abilities in negotiation, problem solving, conflict management and ability to convey a story from data review.Essential Responsibilities/Accountabilities* Analyzes and assesses practices or hospitals to identify opportunities for quality and cost/use improvement and implements quality solutions and tools. Communicates appropriate program(s) solutions, supporting the Health Plan Quality Improvement Plan and corporate network strategies.* Works directly with clinicians and staff at hospitals and practices to plan, deploy, and refine tests of change then implement on a broad scale.* Develops, implements, administers, and evaluates provider quality improvement programs to include baseline and periodic auditing of data submissions in accordance with established measure specifications, tracking targets and performance, communicating with network providers as appropriate, and evaluating outcomes over time to determine appropriate performance improvement support needed. Supports program process provider eligibility for incentive payments, reporting, and annual program modifications.* Collaborates with Value Based payment (VBP) Chief Medical Officer, negotiates at-risk measure and points allocation, updates and maintains quality measures grids for incorporation in VBP provider programs and provider agreements. Ensures alignment with Health Plan quality goals, national measurement efforts, and inclusion of measures driving improved health outcomes and cost savings.* Collaborates with Network Contracting, Medical Directors, Regional Presidents, and Provider Relations to identify program needs and ensure alignment and support with contracting and network management strategies.* Works closely with VBP Account Managers, VBP Information Consultants and VBP Clinical Consultant team to identify opportunities for improvement and supports/contributes to drill down analysis of the measurement data for those identified opportunities.* Responsible for customization and consultative facilitation of VBP clinical quality, cost and use programs or initiatives deployed by VBP providers.* Responsible for the coordination of metric and performance reporting for clinical, cost and use program initiatives taken on by assigned VBP provider partners, working in collaboration with VBP Account Managers and VBP Information Consultants, Analysis and Data team, IT, and others as needed. This includes summary of activity and outcomes to staff and management.* Collaborates with Provider Performance Improvement Consultant to develop and support the engagement strategies for provider collaboratives, alliances and networking initiatives.* Maintains thorough working knowledge of provider performance reporting and registry tools, profiling tools, and databases to support performance reporting in provider programs. Uses available reporting and data to enhance performance improvement activities at provider and group level. Serves as a liaison to assigned hospitals and/or physician practices with performance measurement vendor as applicable.* Researches, analyzes and interprets specific physician, practice, and /or hospital data; identifies opportunities for improvement and recommends appropriate interventions. Facilitates, coordinates and implements provider interventions designed and applicable for assigned provider groups and/or health systems. Provides ongoing consultative support, reporting and evaluation.* Routinely researches national trends in provider quality and performance improvement innovations, programs and technology which have demonstrated meaningful use and sustainable improvements for providers in order to provide timely consultation support to providers.* Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and adhering to the Corporate Code of Conduct.* Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.* Regular and reliable attendance is expected and required.* Performs other functions as assigned by management.Level II - in addition to responsibilities in level I:* Identifies and engages key target hospitals and physicians/practices in provider quality improvement programs.* Provides consultation, complex performance analysis, and coaching expertise to hospital/physician practice quality leadership around strategies and methods of continuous quality improvement. Fosters a culture of continuous improvement that includes the use of performance data to understand health care cost and utilization trends, clinical and condition management analysis, health care cost containment, data quality measurement, and predictive modeling.* Contributes to the development of Quality Exhibits to the provider agreements, making decisions on acceptance or rejection to requested variances from established templates, or recommendations for exhibit modifications.* Represents the Health Plan and collaborates with key community CMOs, CEOs, COOs and other stakeholders on community-wide quality improvement initiatives and grant projects related to VBP and as directed.* Leads and/or presents results on program activities, overall performance, and/or provider performance improvement topics internally and externally, including provider quality improvement forums, committees, and boards, locally, regionally, or nationally.* Identifies, interprets, and implements various quality improvement tools and methods, including but not limited to the model of improvement, process mapping, tests of change or PDSA cycles, advanced access, Lean, and the chronic or planned care model. Takes initiative to document, share findings with team and coach peers in the expansion to additional provider systems as applicable.* Manages and executes multiple high profile provider engagement strategies with other key business areas as appropriate.* Collaborates with the SBP Information Consultant team on quality and cost outcome analytics surrounding provider performance and implements proactive targeted actions/interventions to drive provider behavior change and system-wide improvements.* Leads outreach to targeted providers outside of assigned practice/hospital case load as a means to drive network-wide quality improvements as needed. Identifies patterns of performance based on analytics, collaboratively establishes improvement goals, and coordinates regular outreach to providers who are not actively engaged but could benefit from coaching consultation services.* Anticipates provider improvement needs and informing management of provider performance industry patterns as a result of working with key customers.Minimum QualificationsNOTE:We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.Level 1 -* Bachelor's degree in health care, public/community health, nursing with a valid NYS RN license, and with a minimum of three years' experience in clinical health care improvement in an ambulatory care or facility setting.* A minimum of two years of Health Plan experience in UM, CM, DM or QM preferred* Strong working knowledge of Corporate Medical Policies, Use management programs and guidelines, coding guidelines, NCQA standards, HEDIS, CMS requirements, NYSDOH and other clinical quality mandates & program requirements for providers and health plan.* Knowledge of quality improvement methodologies* Knowledge of health plan and physician office and/or hospital operations.* Knowledge of regulatory programs and the health insurance industry.* Strong problem solving skills. Ability to verify accuracy of data to report information correctly.* Demonstrated consultative skills.* Excellent written and verbal communication skills. Strong interpersonal and presentation skills.* Able to work with all Microsoft Office programs, established databases and analytical tools, presentation software.* Ability to work independently as well as on intra- and interdepartmental matrixed teams.* Must be able to interact with all levels of management, physicians, office staff, and hospital quality leadership. Maintains current and thorough understanding of federal and state regulations and advancements put forth by quality improvement organizations, including but not limited to NCQA, CMS, JCAHO, AHRQ, NQF, and NYS DOH requirements.Level II - in addition to qualifications in level 1:* Minimum seven years of relevant experience (five years of Performance Improvement and two years UM, DM, CM, or QM). Master's Degree preferred.* Seasoned, polished professional who is capable of handling higher profile providers and executing key organizational strategies.* Progressive experience in quality improvement methodologies, theory, techniques, and tools including but not limited to Model for Improvement, Chronic Care/Planned Care Model, process mapping, PDSA cycles.* High level ability to work with mathematical concepts and statistical inference - reads, analyzes, and interprets complex statistical documents and reports. Ability to interpret performance profiling and variation data to draw conclusions for prioritization and engagement for impact.* Knowledge and competency in change agent theory. Demonstrated successful coaching skills.* Recognized as a subject matter expert.* Strong project management skills. Ability to manage multiple high profile/impact projects/providers concurrently with demonstrated outcomes. Exhibits strong organizational and planning skills. Ability to define or identify problems and prioritizes impact or corrective action/implementation to drive execution.* Certification/recognition is required in one or more of the following: care/case management or guided care, Patient-Centered Medical Home practice leadership, PMI, Lean Six Sigma, CPC, or other certification appropriate to scope of work.Physical Requirements* Must have ability to travel to providers throughout specific service area.The Lifetime Healthcare Companies aim to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.OUR COMPANY CULTURE:Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.Equal Opportunity Employer

Keywords: Excellus BlueCross BlueShield, Utica , RN- Clinical Provider Consultant - 004039, Healthcare , Utica, New York

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