Sr. Clinical Business Consultant

Blue Cross Blue Shield of Massachusetts • Hingham, MA

1d

About The Position

Ready to help us transform healthcare? Bring your true colors to blue. The Role The Senior Clinical Business Consultant has broad responsibility for supporting the Cost and Trend agenda for Health and Medical Management and will assist the Director in supporting the division’s strategic direction regarding trend mitigation. The position will be primarily responsible for driving and executing large corporate projects that are clinically focused and managing opportunity assessments with vendors. Working cross-functionally with other BCBSMA departments, this position also analyzes data, new clinical criteria and process workflows to identify savings opportunities and potential clinical trend management. This position leverages strong leadership, organizational and clinical skills, as well as strong health care industry knowledge. The Senior Clinical Business Consultant works with a variety of stakeholders to analyze high-cost claims and members, evaluate clinical trends, and formulate business proposals to mitigate trends and improve quality of care. The Team The Cost, Trend and Reporting team uses clinical expertise and technology together to develop and support strategies to manage the increasing cost of health care. As an integral part of the team, the Senior Clinical Business Consultant is an individual contributor supporting cost and trend initiatives while collaborating with various business units including HMM, Medical Economics, Claims Operations, Enterprise Technology and Legal to support these strategies.

Requirements

• Strong clinical skills and understanding of BCBSMA’s UM/CM operational procedures, Medical & Payment policy, claims processing, insurance & regulatory requirements, billing & payment regulations related to clinical review & payment procedures
• Self-starter and strategic thinker with high energy and drive to meet the needs of a demanding business and clinical environment.
• Strong project management skills with excellent organizational skills
• Demonstrated ability with strategy, analysis, and new work requiring swift decision-making, autonomy, and sound judgment.
• Strong aptitude for effectively collaborating and influencing others at all organizational levels
• Strong interpersonal skills and demonstrated ability to work with physicians, HMM leaders, Sales and other management and administrative staff at all levels of the organization.
• Consultative skills which include ability to implement issue resolution and risk mitigation strategies, and insight to advise and make recommendations.
• Detail-oriented and capable of staying on track while pursuing solutions independently.
• Excellent leadership, communication, negotiation, conflict management and relationship building skills.
• Registered nurse with BSN preferred
• Bachelor’s degree required
• 7+ years clinical experience or in a managed care environment/industry required
• 5+ years management experience required
• Knowledge of APR DRG, HCPCS, CPT, ICD-10 diagnosis and procedure codes and plan benefit designs.
• Proficiency in Word, Excel, PowerPoint, MS Outlook, and strong computer skills including ability to navigate and clinically interpret information from UM and CM systems, NASCO, and Impact Pro.
• Knowledge and understanding of the Enterprise Technology processes to apply guidance and insight to projects.
• Some accounting and financial knowledge.

Responsibilities

• Work with business partners to help drive strategy and process improvements needed to support the Medical Cost Council (MCC) and Trend Oversight (MCOT) projects, including, supporting implementation for mission critical initiatives
• Lead and execute large-scale clinical project implementations designed to mitigate trends and improve quality of care
• Manage the end-to-end opportunity assessment process including collaborating with vendors, coordinating data sharing processes and reviewing the results, making business decisions about moving forward and implementing new programs as indicated.
• Analyze clinical information and utilization trends to propose trend initiatives and develop action plans that mitigate cost risk areas and identify process improvements and efficiencies.
• Assume responsibility for tracking HMM trend mitigation initiatives and help develop solutions to trend projects that present logistical challenges and report to Trend Tiger Team and Medical Cost Council.
• Monitor measures demonstrating the value and impact of divisional cost management strategies and trend initiatives.
• Collaborate with operational leaders to vet cost savings initiatives and bring forth ideas through committees
• Represent department on cross functional workgroups and projects as needed.

Benefits

• We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 11-50 employees