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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. This role will focus specifically on optimizing end-to-end business processes within Utilization Management.

ESSENTIAL FUNCTIONS:

+ Provide deep subject matter expertise in all areas of Utilization Management (UM), including pre-service, concurrent review, and inpatient management, with a specific focus on optimizing end-to-end business processes. (including but not limited to data and metrics, information technology, etc.) that contributes to the effective accomplishment of initiatives tasks and goals. Collaborate on the business strategy, thesis, programs and the identification of strategic opportunities. Support 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 workstreams to accomplish tasks more effectively across different business functions of initiatives. Serve as the subject matter expert and representative for the clinical products team across corporate initiatives and enterprise-wide projects as needed. Maintain a strong working knowledge of the FACETS claims-to-authorization matching workflow and utilize this knowledge to identify and resolve operational and system gaps.

+ Oversee and provide guidance to configuration specialists regarding UM system setup, rule development, and maintenance to ensure alignment with clinical policy and operational goals. Support clear communication across vertical components of the business. Review and support task coordination while identifying potential process improvements related to UM activities and system configuration.

+ Build trusted relationships within CareFirst 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.

QUALIFICATIONS:

**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, Utilization Management (UM) operations, Clinical Product Configuration, Health Plan Claims/Authorization workflows, or related healthcare consulting.

Knowledge, Skills and Abilities (KSAs)

+ Expert-level knowledge of Utilization Management (UM) processes (pre-service, concurrent, inpatient) and applicable regulatory requirements (e.g., CMS, state mandates, accreditation standards).

+ In-depth understanding of medical coding systems (CPT, ICD-10, HCPCS) and the annual code maintenance review cycle.

+ Proven ability to manage and guide system configuration specialists for clinical/UM products.

+ Understands business goals and priorities.

+ Follows evolving market, industry and consumer trends.

+ Effective communication of complex ideas both verbal and written.

+ Exceptional project management, facilitation and organizational skills.

+ Excellent relationship management skills.

+ Strategic thinker, problem solver, and a collaborator who can drive engagement and discussions.

+ Significant experience with MS Office (Excel, PowerPoint, Word).

Salary Range: $88,776 - $176,319

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Guiding Care Product Management

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide 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.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

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

\#LI-SS1

REQNUMBER: 21356