Clinical Business Consultant

The Role
The Clinical Business Consultant for Cost and Trend Management is responsible for identification, outreach and analysis of individual members and membership populations to ensure the most efficient use of resources, improve clinical outcomes, reduce medical expense, and meet stakeholder demands while supporting high-risk and high-cost members.

This position leverages strong analytical and clinical skills, as well as strong health care industry knowledge. The Clinical Business Consultant works with a wide variety of stake holders to analyze high-cost claims and members, evaluate clinical trends, and formulate business proposals to mitigate trend and improve quality of care. This role utilizes all data sources to develop a comprehensive clinical summary for high-cost members and future cost prediction.

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 Clinical Business Consultant supports and leads these strategies while collaborating with various business units including teams across HMM, Sales, Claims Operations, Finance, and Legal.

* This position is eligible for the Flex persona

Key Responsibilities

• Conduct Medical and Cost Assessments on high-cost cases, perform analysis and make recommendations regarding re-adjudication of claims.
• Analyze clinical information from health management systems and claims to provide a clinical summary of a member's course of illness, history of service utilization and costs incurred.
• Analyze provider utilization trends and audit claims using NASCO, Blue Squared and MHK systems.
• Collaborate with operational leaders to develop action plans that mitigate cost risk areas and identify process improvements and efficiencies.
• Monitor existing and emerging issues and trends, and keep relevant stakeholders informed of risk areas and concerns that may require additional attention.
• Partner with Utilization and Care Management to provide clinical support and analysis on high-cost members.
• Assist in mock assessment preparation and identify opportunities with the identification and management of high-cost members.
• Lead and implement new programs and projects to reduce medical trend.
• Collaborate closely with Claims to identify, resolve and recover on operational gaps and payment concerns

Key Qualifications

• Strong clinical skills and understanding of HMM's Utilization Management, Case Management and operational procedures, Medical and Payment policies, claims processing, insurance and regulatory requirements, billing and payment regulations related to clinical review and payment procedures.
• Proven skills analyzing data and identifying clinical trends and overpayments and developing solutions to mitigate gaps and develop business proposals.
• Create and deliver concise presentations leveraging infographics and charts to simplify complex data points
• Demonstrated ability with strategy, analysis, and new work requiring swift decision-making, autonomy, and sound judgment.
• Strong interpersonal skills and demonstrated ability to work with physicians, HMM leaders, and other management and administrative staff at all levels of the organization.

Education and Experience:

• Registered nurse with BSN and 3-5 years in a managed care health plan setting.
• Strong understanding of Utilization Review, Care Management and Medical Polices.
• 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 & Impact Pro.
• Some accounting and financial knowledge.
• Certified Coder - Preferred (ie, CPC, CIC).

#LI-HYBRID

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

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.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.