Healthcare Improvement Quality Outreach Consultant

Excellus BCBS•Rochester, NY

6d•Hybrid

About The Position

This position acts as a quality improvement liaison with physician offices, community agencies, hospitals, and members to promote care management and quality programs. Acts as a member advocate by addressing gaps and barriers to care and educate appropriate use of services through outreach and pilot opportunities. The incumbent promotes programs and services available to Excellus members. Essential Accountabilities: Level I Explores multiple sources of information to identify members who have a gap in care, aligning with HEDIS quality measures and Value Base Payment programs. Assesses member’s needs by applying Health Plan approved guidelines and assessment tools. Makes appropriate referrals to clinical programs. Provides outreach and education via telephone and written communication for members on health care quality metrics, assesses barriers to care, and intervenes as appropriate to assure access or facilitate referrals to other services for the purpose of improving healthcare. (i.e. access to care, preventive health, and chronic diseases). Establishes relationships with providers and community agencies providing services to members. Provides advocacy for members and their support systems, encourages self-sufficiency by addressing social determinants of health, providing effective teaching, and referrals to case and disease management as needed. Participates in collaborative dialogue with Hospital Executives and/or physician leadership to assure performance and quality measures and outcomes measurement are aligned with corporate HCI quality goals for various programs as applicable. Coordinates, presents, and promotes clinical programs to provider offices in coordination with Strategic Business Partners, Risk Adjustment, and Provider Relations. Educates providers and community agencies on information regarding services and programs available to Excellus members. Pilots and collects data on new methods of promoting quality health outcomes to routinely assist in the development and maintenance of experience and health quality programs. Serves as a resource to numerous health care improvements project teams in areas of gap closure. Leads project teams and becomes subject matter expert (SME) to drive new methods/interventions to promote quality health outcomes and programs. Interacts with diverse members and professionally communicates with physicians and practice staff. Manages a caseload productively and keeps appropriate documentation according to health plan standards. Meets or exceeds established departmental metrics including, but not limited to call volumes, reach rate and gap closure rate. Facilitates adherence to provider Service Level Agreements (SLA). Adheres to all compliance standards and regulatory requirements. 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 Accountabilities) Prioritizes work and provides instruction, advice and guidance to more junior level staff as it relates to processes, procedures and business systems, e.g. training/mentoring. Collaborates with junior level staff and is a positive influence within a team unit structure. Professionally interacts with the provider community and manages key provider practices. Serves as the point person to make decisions in the absence of the Supervisor Serves at intermediary between staff and management to alert supervisor of potential problems. Collaborates with other key departments regarding changes in processes/systems and identifies problems and recommends logical and effective solution. Reviews metrics on a weekly basis, and as needed, applying continuous quality improvement principles to optimize both process and outcome metrics. Follows the PDSA model and reviews, at least quarterly, the embedded practice outcomes, identifies best practices, and offers opportunities for improvement working collaboratively with Strategic Business Partners, Risk Adjustment, and Provider Relations. Researches best practice across other health plans and understands health care improvement trends and related needs. Assists with the development and implementation of new innovative care management (pilots) and quality programs including reviewing and presenting outcomes at quality monitoring and planning committees as well as provider offices.

Requirements

A minimum of three (3) years’ experience in health/human services.
Associates degree in human services or business-related field.
In lieu of degree, a minimum of four years direct provider and member contact.
Experience with project management.
Experience working with member populations from one or more lines of business (Commercial, SafetyNet, Medicare).
Experience with giving formal/informal presentations to small/large audiences.
Proficiency in MS Office programs: Word, Excel, PowerPoint
Self-motivated and able to work independently as well as on matrixed teams.
Ability to problem solve for effective conflict resolution.
Minimum of five (5) years direct experience with the provider and member community.
Excellent communication and presentation skills.
Experience with working with member populations from all lines of business (Commercial, SafetyNet, Medicare).
Subject Matter Expert in HEDIS and VBP quality measures.
Experience and proven success with PDSA process improvement cycle.
Demonstrated skills in quality principles especially root cause analysis and problem solving.
Knowledge of health insurance industry, federal and state regulations, accreditation standards, and advancements put forth by quality improvement organizations (including but not limited to NCQA, CMS, The Joint Commission, and NYS DOH).
Demonstrated leadership skills.

Nice To Haves

Bachelor’s degree is preferred.
LPN or Medical Assistant preferred.
Experience with iFacets claims processing and coding preferred.
Knowledge of preventive health activities and community agencies preferred.

Responsibilities

Act as a quality improvement liaison with physician offices, community agencies, hospitals, and members to promote care management and quality programs.
Act as a member advocate by addressing gaps and barriers to care and educate appropriate use of services through outreach and pilot opportunities.
Promote programs and services available to Excellus members.
Explore multiple sources of information to identify members who have a gap in care, aligning with HEDIS quality measures and Value Base Payment programs.
Assess member’s needs by applying Health Plan approved guidelines and assessment tools.
Make appropriate referrals to clinical programs.
Provide outreach and education via telephone and written communication for members on health care quality metrics, assess barriers to care, and intervene as appropriate to assure access or facilitate referrals to other services for the purpose of improving healthcare.
Establish relationships with providers and community agencies providing services to members.
Provide advocacy for members and their support systems, encourage self-sufficiency by addressing social determinants of health, providing effective teaching, and referrals to case and disease management as needed.
Participate in collaborative dialogue with Hospital Executives and/or physician leadership to assure performance and quality measures and outcomes measurement are aligned with corporate HCI quality goals for various programs as applicable.
Coordinate, present, and promote clinical programs to provider offices in coordination with Strategic Business Partners, Risk Adjustment, and Provider Relations.
Educate providers and community agencies on information regarding services and programs available to Excellus members.
Pilot and collect data on new methods of promoting quality health outcomes to routinely assist in the development and maintenance of experience and health quality programs.
Serve as a resource to numerous health care improvements project teams in areas of gap closure.
Lead project teams and become subject matter expert (SME) to drive new methods/interventions to promote quality health outcomes and programs.
Interact with diverse members and professionally communicate with physicians and practice staff.
Manage a caseload productively and keep appropriate documentation according to health plan standards.
Meet or exceed established departmental metrics including, but not limited to call volumes, reach rate and gap closure rate.
Facilitate adherence to provider Service Level Agreements (SLA).
Adhere to all compliance standards and regulatory requirements.
Consistently demonstrate 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.
Maintain high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Perform other functions as assigned by management.
Prioritize work and provide instruction, advice and guidance to more junior level staff as it relates to processes, procedures and business systems, e.g. training/mentoring.
Collaborate with junior level staff and be a positive influence within a team unit structure.
Professionally interact with the provider community and manage key provider practices.
Serve as the point person to make decisions in the absence of the Supervisor.
Serve as intermediary between staff and management to alert supervisor of potential problems.
Collaborate with other key departments regarding changes in processes/systems and identify problems and recommend logical and effective solutions.
Review metrics on a weekly basis, and as needed, applying continuous quality improvement principles to optimize both process and outcome metrics.
Follow the PDSA model and review, at least quarterly, the embedded practice outcomes, identify best practices, and offer opportunities for improvement working collaboratively with Strategic Business Partners, Risk Adjustment, and Provider Relations.
Research best practice across other health plans and understand health care improvement trends and related needs.
Assist with the development and implementation of new innovative care management (pilots) and quality programs including reviewing and presenting outcomes at quality monitoring and planning committees as well as provider offices.