Clinical Business Consultant

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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 stakeholders 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 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.

• 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.

• 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 over payments 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.

• Registered nurse with BSN and 3-5 years in a managed care health plan setting.
• Strong understanding of Utilization Review, Care Management and Medical Policies.
• 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).

High school degree or equivalent required unless otherwise noted above.

Hingham

Full time

$ - $

The job posting range is the lowest to highest salary we in good faith believe…