Job Description

Job Description:

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 members 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.

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 addition to using this differentiated approach to place new hires it also provides guideposts for employee development and promotional opportunities.

All Levels

• A minimum of three (3) years experience in health/human services.
• Associates degree in human services or business-related lieu of degree a minimum of four years direct provider and member contact. Bachelors degree is preferred.
• LPN or Medical Assistant preferred.
• 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.
• Experience with iFacets claims processing and coding preferred.
• Knowledge of preventive health activities and community agencies preferred.

Level II (in addition to Level I Qualifications)

• 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.

Physical Requirements:

• Ability to travel across the health plan service regions as needed.

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One Mission. One Vision. One I.D.E.A. One you.

Together we can create a better I.D.E.A. for our communities.

At the Lifetime Healthcare Companies were on a mission to make our communities healthier and we cant do it without you. We know diversity helps fuel our mission and thats why we approach our work from an I.D.E.A. mindset (Inclusion Diversity Equity and Access). By activating our employees experiences skills and perspectives we take action toward greater health equity.

We aspire to reflect the communities we live in and serve and strongly encourage people of color LGBTQ people people with disabilities veterans and other underrepresented groups to apply.

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

Compensation Range(s):

N6: $22.50 - $35.00

N7: $23.75 - $37.70

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including but not limited to budget available prior experience knowledge skill and education as they relate to the positions minimum qualifications in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance retirement plan wellness program paid time away from work and paid holidays.

Please note: The opportunity for remote work may be possible for all jobs posted by the Univera Healthcare Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability or status as a protected veteran.

Required Experience:

Contract

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