Business Consultant; Remote

Purpose: The Business Consultant provides expertise in tailored, strategic, and critical work to help design, launch, and execute programs that support initiatives in the changing healthcare environment. Specifically, this position is part of the Appeals and Grievances Government Programs team and supports the development, implementation, and optimization of business processes and strategic initiatives for the Government Programs Appeals and Grievances function.

This role serves as a key liaison between the Appeals and Grievances team and interdisciplinary partners including Claims Operations, Service Operations, Utilization Management, Payment Integrity, and Compliance to improve process efficiency, support regulatory compliance, and strengthen operational performance. Working under the direction of the Director, Medical Review and Appeals, the Business Consultant helps drive initiatives that support accurate, timely, and compliant handling of appeals and grievances across Medicare and Medicaid lines of business.

The incumbent will work remotely from within the greater Baltimore metropolitan area and is expected to come into a Care First location periodically for meetings, training and other business-related activities. The ideal candidate has direct experience with appeals and grievances for government programs lines of business in a payor organization.

• Provides subject matter expertise in appeals and grievances while acting as a liaison for interdepartmental collaboration, including utilization management, claims operations, service operations, payment integrity, and compliance. Contributes to the effective accomplishment of initiatives, tasks and goals.
• Collaborates on business strategy, thesis, programs and identification of strategic opportunities; supports cross-functional teams and projects to deliver value.
• Designs and runs dashboards to support clear communication; reviews and supports task coordination while identifying potential process improvements.
• Develops and finalizes budgets, policies, and documentation related to appeals and grievances processes; ensures compliance with State and Federal regulations and NCQA accreditation standards.
• Coordinates all aspects of Appeals and Grievance government audits to ensure favorable outcomes; tracks action items and ensures timely completion.
• Builds trusted relationships within Care First to identify synergies and improve task execution across the organization; communicates strategy, programs and next steps to leadership and partners.

• Education Level: Bachelor's Degree or equivalent experience (minimum 4 additional years of relevant work experience).
• Experience: 5 years in business development, operational technology support, general business operations and/or consulting.
• Preferred Qualifications: Direct experience with appeals and grievances for government programs lines of business in a payor organization.

• Understands business goals and priorities.
• Follows evolving market, industry and consumer trends.
• Effective communication of complex ideas in verbal and written form.
• Exceptional project management, facilitation and organizational skills.
• Excellent relationship management skills.
• Strategic thinker, problem solver, and collaborator who can drive engagement and discussions.
• Significant experience with MS Office (Excel, PowerPoint, Word).
• Ability to meet deadlines and manage multiple customer service demands with excellence.

Salary Range: $88,848 – $176,462

The disclosed range is specific to the position and considers factors such as scope, experience, and location. Additional benefits include a comprehensive benefits package, incentive programs, and 401(k) contributions.

Care First Blue Cross Blue Shield is an Equal Opportunity (EEO) employer. The Company provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Incumbent must immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work on Federal health care programs. The role is primarily seated, with occasional walking or standing and the handling of objects up to 25 pounds.

Must be eligible to work in the U.S. without sponsorship.