Sr. Clinical Business Consultant

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.

Key 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.

Key Qualifications:

• 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.

Education and Experience:

• 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.

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.