Business Consultant; Remote

Resp & Qualifications

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 will be 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.

We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a Care First location periodically for meetings, training and/or other business-related activities. The idea candidate will have direct experience with appeals and grievances for government programs lines of business in a payor organization.

• Provides subject matter expertise in the area of appeals and grievances while acting as a liaison for interdepartmental collaboration to include but not limited to utilization management, claims operations, service operations, payment integrity and compliance. The business consultant contributes to the effective accomplishment of initiatives tasks and goals. Collaborates on the business strategy, thesis, programs and the identification of strategic opportunities.
  
  Supports cross-functional teams and projects between division, and others to deliver value to team. Proactively identify ways, means, and platforms to build synergy and mutually reinforcing work streams to accomplish tasks more effectively across different business functions of initiatives. Coordinates all aspects of Appeals and Grievance government audits to ensure favorable outcomes; tracks action items and ensures timely completion.
• Designs and runs dashboards to support clear communication across vertical components of business. Reviews and supports task coordination while identifying potential process improvements. Develop and finalize budgets, policies, and other documentation related to appeals and grievances processes and procedures. Coordinates, tracks, and ensure timely completion of action items assigned to Appeals & Grievance department and submits reports supporting same. Develops and updates Medicaid and Medicare Advantage policies and SOPs with input from key stakeholders that comply with State and Federal regulations and NCQA accreditation standards;
  
  maintains current policies and SOPs in SAI
  360.
• Build trusted relationships within Care First to deepen subject‑matter expertise, find opportunities to synchronize with core operations, and ensure close coordination with the central team in the execution of their areas of responsibility within the division. Identifying opportunities for synergies to improve task execution across the organization. Working collaboratively with other support partners in our current and upcoming programs. Communicating strategy, programs, and next steps to leadership and our partners.

Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 5 years experience in business development, operational technology support, general business operations and/or consulting experience.

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…