Health Outcomes Specialist I/II

Excellus BCBS•Rochester, NY

2d•Hybrid

About The Position

The Health Outcomes Specialist I-II supports the Health Outcomes & Community Impact (HOCI) strategic plan, goals, enterprise-wide measures, and efforts to achieve improvement across our markets and populations. The role supports the design, implementation, and evaluation of initiatives that improve measurable health outcomes across priority member populations. This role ensures that interventions designed to address disparities lead to demonstrable improvements in clinical outcomes, utilization, community impact and member experience. Working within the HOCI team, the Health Outcomes Specialist partners with internal stakeholders including Quality, Healthcare Management, Medical Governance, Provider Network, Pharmacy, Data Analytics, and Marketing to operationalize strategies that improve outcomes for members experiencing disproportionate health risks or barriers to care. This role translates population health insights and equity-informed strategies into actionable interventions, program implementation, and outcome measurement.

Requirements

Minimum of two (2) years’ experience working within a health plan related to Health Equity/ Population Health Management or other clinically related program development with Bachelor’s degree in related field.
In lieu of a degree, minimum of eight (8) years’ experience working within a health plan in a role related to population health management/case management interventions/programs or other clinically related program development required.
Five (5) years of clinical experience required (RN, LPN, BH, MPH, etc.)
PMP certification 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.
Subject matter expert on the development of clinical strategic interventions.
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.
Demonstrated strengths with emotional intelligence including keen collaboration, consultative relationship building, and consensus building skills.

Nice To Haves

PMP certification preferred.

Responsibilities

Partners with leadership on sharing and updating a robust health equity and community health training initiative that spans the entire enterprise as well as externally.
Research and maintains sound knowledge of health equity, evidence-based improvement interventions, industry trends, best practices, and benchmarks to deliver innovative and effective solutions for the management of the HOCI strategy.
Consults on the development of the health equity data infrastructure to ensure appropriate creation of downstream clinical interventions to mitigate health disparities.
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.
Consults with key internal stakeholders including medical directors, operational and strategic leadership, SMEs, and regional directors as well as external network/other Blues plans regarding the nature of the opportunity identified, potential interventions, and desired and expected outcomes.
Evaluates initiatives and determines key benchmarks in collaboration with health equity stakeholders for its use in subsequent evaluations.
Analyzes, compiles and implements interventions to incorporate into strategic assessments; creates comprehensive strategic proposals to improve health outcomes.
Collaborates with other departments early in the initiative development cycle including quality, provider engagement, customer care, VBP programs, corporate communications/marketing, clinical operations, and others, in regard to cross-functional business processes, program development initiatives and timelines.
Collaborates with the Quality department to facilitate health equity accreditation requirements.
Consults with the CIP team to incorporate a community-based approach on projects, processes and initiatives.
Assesses member, provider and other key stakeholders’ experience related to new or updated initiatives and plans proactively to address their concerns and needs positively.
Oversees 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.
Provides reports and recommendations to the Utilization Management/Case Management (UM/CM) team for action.
Responsible for defining, coordinating, and communicating the ongoing monitoring of existing programs in HOCI and other areas as relevant to ensure meaningful intervention outcomes and value are realized and partner with key stakeholders to support strong results.
Serves as subject matter expert in maintaining the UM/CM training program for PHE and other key stakeholder roles.
Represents Medical Services on Health Plan-wide cross functional process improvements teams, as requested by manager/director.
Coordinates HOCI committees to define, prioritize and facilitate initiatives, as appropriate.
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.
Participates in, facilitates, and may manage all aspects of meetings within HOCI 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 and recommendations 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 HOCI team and build awareness, support, and participation for the process and team.