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Population Health Engagement Program Development Specialist I/II - 008280

Company: Excellus BlueCross BlueShield
Location: Utica
Posted on: June 8, 2021

Job Description:


The Program Development Specialist develops and monitors strategic initiatives for all aspects of work related to affordability initiatives or Population Health Engagement. Working within defined processes, leads analysis to identify opportunities for total cost of care improvement including impactable provider and/or member programs, trends, and UM/CM. This position consults with key internal stakeholders including competitive intelligence, market insights, operational and strategic leadership, SMEs, regional directors and medical directors as well as external network/other Blues plans regarding the nature of the opportunity identified, potential interventions, and desired and expected outcomes. The Specialist conducts ongoing review and research of health plan cost containment strategies including UM/CM and related interventional literature and current clinical evidence of effectiveness. The Specialist creates comprehensive strategic proposals based on in-depth research of best practice initiatives and benchmark Health Plans, and competitor information, leveraging both internal and external resources available, to impact Health Plan medical expense trends. The incumbent develops reports and recommendations for action and facilitates the vetting and approval process. Facilitates smooth transition to long-term operational owners of new or expanded initiatives and creates and maintains roadmaps for program expansion. Manages oversight of the ongoing roadmap execution as well as measurement of success of implemented interventions on a clear cadence and appropriately intervenes to ensure success. As needed, manages small to medium projects related to program development activities. The Specialist serves as a subject matter expert for the development of strategic interventions.

Essential Responsibilities/Accountabilities:

Analysis and identification of opportunities, business case/proposal:

  • In conjunction with key analytics staff, identifies significant opportunities for improvement across UM/CM/DM and other areas and conducts drill down analysis of the measurement data for those identified opportunities. Works closely with the Trend and Analytics, Quality Health Informatics, Data Warehouse project resources/leads, and Actuarial Dept contacts, for consultative purposes to obtain highly complex data and reports, as necessary.
  • Compiles comparative analysis of benchmark and competitor results to incorporate into strategic assessments; creates comprehensive strategic proposals
  • Based on trend analysis, collaborates on potential cost management opportunities with provider contracting and network management to drive forward comprehensive savings strategies
  • Analyzes gaps in the current care and utilization management programs and processes and identifies opportunities for program enhancement.
  • Collaborates with other departments early in the initiative development cycle including provider contracting, network management, provider engagement, VBP programs, sales, underwriting, actuary, product, compliance, accreditation, procurement, quality, corporate communications/marketing, clinical operations and others, in regards to cross-functional business processes, accreditation requirements, regulatory issues, and other initiative impacts/considerations to ensure provider types, contract language and reimbursement rates/approaches support policy language, corporate strategies, and program development initiatives and timelines.
  • Assesses member, provider, facility, and other key stakeholders' experience related to new or updated initiatives and plans proactively to address their concerns and needs positively.
  • Ensures identified interventions are complaint with DOH, NCQA, URAC and Medicare requirements.
  • Generates key stakeholder awareness and interest and incorporates key perspectives from stakeholders in strategic proposals to enable stronger consensus
  • Takes primary responsibility for vendor relationships associated with vendor partners as needed, including identification of key vendors, nurturing vendor contacts, RFI/RFP creation and strong oversight, pricing negotiations, contract facilitation with legal and other entities, monitoring vendor SLAs/PGs as needed

Ongoing research/knowledge/networking:

  • Conducts research on and maintains sound knowledge of the evidence-based improvement interventions, industry trends and bench marks in order to deliver innovative and effective solutions for the management of Health Plan medical trends.
  • Networks with key contacts at other health plans/Blues plans/Association to enable sharing of ideas and best practices in the organization's best interests.


  • Provides reports and recommendations to the Utilization Management/Case Management team for action.
  • Responsible for defining, coordinating, and communicating the ongoing monitoring of existing programs in UM/CM/DM and other areas as relevant to ensure meaningful intervention outcomes and value are realized and partner with key stakeholders to support strong results.
  • Facilitates the transition of new or updated initiatives to the long-term operational owner over an agreed upon window of time, with clearly documented reference materials, and a documented monitoring agreement to ensure success and value for the organization. May include roadmap for expansion and support ongoing expansion in collaboration with operational owner.

Process Engineering:

  • Leads and facilitates processes needed to analyze and improve processes and workflows.
  • Organizes and facilitates large educational and re-engineering sessions. Facilitates interdepartmental coordination and communication with all Care Management functional areas, such as, but not limited to Case Management, Utilization Management, Behavioral Health, Medical Claim Review and Audit, Health Promotion, Disease Management, to support delivery of high quality, timely customer solutions.

General Role Responsibilities:

  • Creates strategic business cases in support of Affordability or PHE in general
  • Participates in and may facilitate all aspects of meetings within affordability and in support of program development as needed
  • As needed, independently serves as project manager for small to medium initiatives specific to the affordability goals and divisional goals within PHE.
  • Represents Medical Services on Health Plan-wide cross functional process improvements teams, as requested by manager/director.
  • Contributes to the team's knowledge and proficiency by sharing key insights and learnings with peers and leadership as appropriate
  • Collaborates with other clinical departments in regards to cross functional business processes, accreditation requirements, and regulatory issues.
  • May assist with/Develop policies and procedures for the Utilization Management/Case Management process.
  • Serves as subject matter expert in maintaining the Utilization Management/Case Management training program for PHE and other key stakeholder roles.
  • May facilitate the development and implementation of hospital, practitioner, and office staff improvement initiatives.
  • Maintains Program Development prospective/implemented project tracking.
  • Accepts responsibility for personal professional education requirements per departmental policy.
  • Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
  • 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 Level I essential responsibilities/accountabilities):

  • Participates in, facilitates, and may manage all aspects of meetings within affordability and in support of program development as needed
  • Mentoring and Coaching of program development team within the department and others in similar roles as appropriate
  • Provides input into strategic proposals for program development team
  • Acts as an ambassador of the team function throughout the organization to ensure consensus, collaboration, and support
  • Provides presentations to key stakeholders to share the vision and mission of the affordability and program development team and build awareness, support, and participation for the process and team
  • As needed, meets with employer groups to present Medical Management/Member Program management reports, and provides consultation on activities that will improve program results or help manage costs.

Minimum Qualifications

NOTE: 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.

All Levels:

Level I:

  • Bachelor's degree in related field with a minimum of two years' experience working within a health plan in a role related to utilization management/case management interventions/programs or other clinically related program development. In lieu of a degree, must have a minimum of seven years' experience working within a health plan in a role related to utilization management/case management interventions/programs or other clinically related program development. Clinical experience; medical coding experience; PMP certification are preferred.
  • Working knowledge of best practices and tools related to project management and process engineering/improvement
  • Working knowledge of Corporate Medical Policies, InterQual and Milliman & Robertson guidelines, NCQA standards, URAC requirements, HEDIS, CMS requirements, and NYSDOH medical management mandates & program requirements.
  • Demonstrates effective verbal communication skills and strong writing capabilities.
  • Developing skills in reading, analyzing and understanding analytics reports and documents.
  • Understands basic concepts of return on investment measurement
  • Exhibits excellent organizational, planning, and project management skills. Makes decisions using solid judgment skills to impact identified problems.
  • Resourceful and appropriately tenacious in the face of varied opinions to gain consensus.
  • Exhibits leadership through meeting facilitation
  • Exhibits key LTW attributes and values at all times

Level II (in addition to Level I minimum qualifications):

  • Minimum of six years' experience working within a health plan in a role related to utilization management/case management interventions/programs or other clinically related program development.
  • Strong understanding of and preferred experience with Return on Investment measurement and concepts
  • Experience with process development and refinement, experience leading projects whether formal or informal
  • Reads, analyzes, and understands complex analytics reports and documents. Able to identify further areas of exploration/opportunity and guide analytic requests to explore targeted opportunities
  • Has demonstrated strengths with emotional intelligence including keen collaboration, consultative relationship building, and consensus building skills.

Physical Requirements:

  • Works primarily from a desk for a majority of the workday.

The Lifetime Healthcare Companies aims 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.


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 , Population Health Engagement Program Development Specialist I/II - 008280, Other , Utica, New York

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