Sr. Medicare Ops Business Consultant
Capital BlueCross
hace 3 horas

The Senior Medicare Operations Consultant is responsible for providing analytical support to various business areas and customers.

Also acts as subject matter expert providing technical and / or business knowledge to support decision making processes.

Mentors business consultants and business analysts. Collaborates on the development of Medical Value initiatives and business intelligence platforms.

Compliments Consultant responsibilities and initiative support by gathering and interpreting customer requirements, competitive information and industry standards.

Duties and Responsibilities :

  • 20% - Participate in engagements with specific business areas and customers, such as : External customers, Sales, Marketing, Quality Management, Network Management, Actuarial, Finance, Pharmacy Services, Care Management, and Operations with a focus on being a subject matter expert providing technical and business level of involvement to support information needs in the decision making process.
  • 20% - Responsible for the successful delivery of the design, development and implementation of analysis and research on the cost and utilization trends relative to product, program, network, benefit design, employer group, etc.
  • and the communication of this information to key internal and external stakeholders.

  • 10% - Ensures extensive research design, comprehensive data collection and sound statistical methods are applied to the cost and utilization forecasts, corporate reporting, programs, and corporate projects.
  • 10% - Ensures appropriate development of research proposals, protocols, information needs, and data analysis plans to support the analysis and assessment of internal and vendor programs involving sales initiatives, contracting, quality improvement, clinical management, cost and utilization trend analysis and benchmarking, pharmacy benefit management, medical affairs, and other Corporate initiatives.
  • 10% - Mentors business areas in the initial assessments, requirements, project plans, solutions, research and selections with a focus on data, information reporting, and analysis.
  • Lead project task execution by ensuring progress, organizing project data, and coordinating team meetings.

  • 10% - Focuses on project collaboration with business areas or external customers where a proficiency in business knowledge exists.
  • 10% - Provides information to customers / clients in development of engagements, materials, events, initiatives, committees, meetings and presentations by gathering needed information and using appropriate frameworks and models in the development of assessment materials.
  • 10% - Provides support for other analytical and reporting needs, trend analysis, financial improvement plans, compliance and regulatory reporting coordination (NCQA, HEDIS, DOH, HHS, CMS, FEP, OPM).
  • Individual will be responsible for performing retrospective trend analysis, business requirement gathering, customer needs assessments, documentation of data needs / source mapping, competitive and industry information.

    Skills :

  • Ability to drive results to completion while managing multiple projects and priorities competing for resources. Ability to compliment Principal Consultants in their responsibilities and roles.
  • Experience and proficient knowledge of project management techniques. Includes experience in planning, organizing, leading and managing multiple projects concurrently.
  • Ability to perform knowledge transfer to Business Consultants.
  • Ability to communicate proficiently, effectively, and consistently with all levels of internal / external personnel to prepare written materials and oral presentations for technical and non-technical audiences.
  • Includes seasoned negotiation / persuasion skills to lead meetings and ensure mutually agreeable solutions among multiple departments / Plans, as well as, successful completion of a project.

  • Advanced problem-solving and structured analysis / design techniques. Includes the ability to understand complex inter-related systems and to independently resolve business and technical problems encountered.
  • Ability to adapt to constantly changing priorities. Includes ability to work with minimal supervision and to inspire teamwork among diverse groups.
  • Knowledge :

  • Experience with quality studies, population based analysis, disease management, health care financial trend analysis, modeling, and a background in research methodologies and statistics.
  • Knowledge of managed care insurance and business processes, data, systems, and applications for claim payments, network and provider contract administration and management.
  • Knowledge of or ability to understand and interpret NCQA, JCAHO, American Accreditation HealthCare Commissions / URAC standards, HEDIS, CMS and HHS requirements.
  • Knowledge and experience in Crystal, Microsoft Access, Microsoft Excel, reporting and testing software, as well as other Microsoft Office Suite tools.
  • Experience :

  • Minimum 5-8 years technical or operational work experience.
  • Education and Certifications :

  • Prefer a Bachelor's Degree in one of the following; mathematics, statistics, business administration, health planning and administration, finance, economics.
  • Work Environment :

    Working environment includes typical office conditions.

    Physical Demands :

    While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.

    The employee must be able to work over 40 hours per week. The employee must occasionally lift and / or move up to 5 pounds.

    Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.

    Working environment includes typical office conditions.

    Other :

  • Performs other related duties and assignments as directed.
  • TravelTravel, including overnight excursions may be required.
  • Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity / affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.

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