Job Description
Overview
We are seeking an experienced and strategic Senior Clinical Consultant with deep expertise in health plan and payer related clinical programs to lead and support clinical initiatives across client engagements. This role partners with healthcare payer organizations—including commercial, Medicare, and Medicaid plans—to assess, design, implement, and optimize clinical and operational programs. The ideal candidate brings a strong clinical background (e.g., nursing, pharmacy, medicine), deep knowledge of healthcare operations, and a proven track record in clinical consulting or health systems initiatives such as utilization management (UM), care management (CM), quality improvement, and clinical program optimization.
- Key Responsibilities:
- Collaborate with payer clients to evaluate clinical workflows, utilization management structures, care management programs, quality initiatives, and care delivery models.
- Design and implement strategies to improve outcomes related to medical cost management, clinical appropriateness, operational efficiency and member health outcomes.
- Analyze clinical data—including claims, risk adjustment, HEDIS/QRS, and authorization trends—to identify performance improvement opportunities.
- Serve as a subject matter expert (SME) in clinical best practices, regulatory compliance (CMS, NCQA, URAC), benefits administration, and managed care standards.
- Lead clinical workstreams in projects involving EHR optimization, related to care management transformation, population health strategies, or clinical program optimization.
- Translate clinical and operational requirements into technical specifications for product or system implementations (e.g., UM platforms, care management tools).
- Deliver presentations, workshops, and training to clinical and executive stakeholders within health plans.
- Support business development by contributing to payer?focused proposals, white papers, solution design, and client presentations.
- Mentor junior consultants and serve as a trusted advisor to client teams.
- Qualifications:
- Bachelor’s or Master’s degree in Nursing, Medicine, Pharmacy, Public Health, or related field.
- Clinical licensure (e.g., RN, MD, PharmD) strongly preferred.
- 5–10+ years of experience in clinical roles with at least 3 years in the payer space, such as utilization management, care management, quality, health plan operations, or consulting to health plans.
- Experience with healthcare technology platforms (e.g., EHR systems like Epic or Cerner, UM/CM clinical decision support).
- Deep knowledge of healthcare regulations (e.g., CMS, HIPAA, Joint Commission) and state regulatory requirements, NCQA/URAC accreditation standards, benefits policy, and clinical quality programs.
- Strong analytical, communication, and stakeholder engagement skills.
- Willingness to travel up to 5% depending on client location and engagement.
- Sr Director or above experience in UM/CM health plan operations
- Preferred Qualifications:
- Experience with value-based care models, risk adjustment programs, ACO or population health strategies.
- Certification in Lean Six Sigma, PMP, or healthcare quality (e.g., CPHQ).
- Familiarity with data visualization tools (e.g., Tableau, Power BI) and clinical analytics platforms.
Pay: $109,648.93 - $132,050.31 per year
- Experience:
- payer space: 3 years (Required)
- clinical: 5 years (Required)
- License/Certification:
- RN, MD or PharmD license? (Required)
Work Location: Remote
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