Population Health Engagement Program Development Specialist I/II - 008280
Company: Excellus BlueCross BlueShield
Posted on: June 8, 2021
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
Analysis and identification of opportunities, business
- 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
- 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
- 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
- Assesses member, provider, facility, and other key
stakeholders' experience related to new or updated initiatives and
plans proactively to address their concerns and needs
- 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
- 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
- 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.
- 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
- 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
- Contributes to the team's knowledge and proficiency by sharing
key insights and learnings with peers and leadership as
- 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
- May facilitate the development and implementation of hospital,
practitioner, and office staff improvement initiatives.
- Maintains Program Development prospective/implemented project
- 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
- Participates in, facilitates, and may manage all aspects of
meetings within affordability and in support of program development
- 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
- 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
- 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.
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
- 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 &
- Demonstrates effective verbal communication skills and strong
- Developing skills in reading, analyzing and understanding
analytics reports and documents.
- Understands basic concepts of return on investment
- 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
- 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
- Has demonstrated strengths with emotional intelligence
including keen collaboration, consultative relationship building,
and consensus building skills.
- 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.
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 , Population Health Engagement Program Development Specialist I/II - 008280, Other , Utica, New York
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