SCOPE OF ROLE

The Medical Cost Management Consultant is a critical part of the Bright Health Plan Medical Cost team and is responsible for researching, completing detailed analysis, and the successful implementation of results to achieve medical cost savings goals. The position will partner with multiple cross-functional teams and will be accountable to analyze and develop executable initiatives. The Consultant role will own new idea development, market research, business case development, and execution support of assigned initiatives. The Consultant will be responsible for managing opportunities across multiple markets, lines of business (Individual and Family Plans, Medicare Advantage and Employer) and functional areas (Clinical, Network, Operations, etc).

ROLE RESPONSIBILITIES

The Medical Cost Management Clinical Consultant job description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Bring together multiple sources of data to design and develop business cases and recommendations that solve medical cost challenges.
  • Partner with analytics resources to define data requirements and analyze results to estimate medical cost impacts.
  • Use data to complete operational impact assessments to identify cost and requirements for implementing recommendations.
  • Produce clear and concise summaries of findings and recommendations for easy consumption by a variety of audiences through a variety of media: presentations, email summaries, executive summaries, and oral discussions.
• Support execution of approved initiatives to ensure high quality and successful implementations.
• Investigate key business problems by analyzing data to identify patterns and trends in cost and utilization, translate the analysis into insights, and use the results to define opportunities to drive business action.
• Complete market and competitive research to drive new ideas to pursue.

SUPERVISORY RESPONSIBILITIES

• This position does not have supervisor responsibilities.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s Degree in Computer Science, Economics, Healthcare, or a related field
• Two (2) or more years of experience in analytical work within the healthcare industry specifically focusing on healthcare claims (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.)
• Experience with MS Excel functions that include working with large data sets, creating standardized reports, utilizing vlookups/xlookups and advanced functions/ formulas, creating, using, and interpreting pivot tables, filtering, and formatting.
• Knowledge of healthcare financial terms such as cost, utilization, Per Member Per Month (PMPM) and revenue.
• Working knowledge in creating and running complex queries using SQL or other programs (i.e. Visual Basic coding, etc.)
• Experience creating data visualizations with Tableau, MS Power BI or other visualization tool(s).
• Understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG’s), Ambulatory Patient Groups (APG’s), Ambulatory Payment Classifications (APC’s), and other payment mechanisms.

PROFESSIONAL COMPETENCIES

• Previous health plan experience, preferably in one of more of the following areas: Utilization Management, Clinical Innovation, Care Management
• Knowledge of medical literature evaluation
• Excellent written and verbal communication skills
• Ability to perform critical analysis of complex problems and propose appropriate solutions
• Strong analytical skills, work ethic, problem solving ability, and overall positive attitude
• Demonstrated flexibility, organization, and self-motivation
• Adaptable to change

LICENSURES AND CERTIFICATIONS

• No licensures and/or certifications are required for this role.

WORK ENVIRONMENT

• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Some travel may be required.