Position Description
Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”
This position is responsible for providing clinical insights, support and guidance to improve health plan performance based on analytics to Capital Blue Cross’ sales and account management team as well as provides direct clinical support to the Medical Director of Client Analytics. Highly collaborative and consultative approach in supporting a strategic segment of commercial clients.
Responsibilities And Qualifications
Duties and Responsibilities:
- 20% - Coordinate, organize, and facilitate data analysis for client meetings. Conduct research on medical issues in addition to member specific cases. Represent Medical Director, Client Analytics at internal and external meetings in his/her absence. Work closely with other departments to prepare for client meetings and provide responses to client requests
- 20% - Provide clinical consultation based on analysis and identification of key drivers of results (population health trends, performance results, engagement, and opportunities for improvement); support clinical programs and services that align with the client’s strategy and help drive short- and long-term priorities
- 20% - Facilitate weekly/monthly clinical and financial status reports for strategic accounts
- 10% - Provide ad hoc clinical summaries, conduct research of claims and relay clinical implications of care rendered for members with likelihood of future healthcare costs to support the needs of account executives and their respective employer groups. Identify potential cases for care management and initiate steps for referral
- 10% - Maintains relationships with employer groups, brokers and coalitions to support sales efforts; facilitate Executive Clinical Reviews as needed; provide clinical expertise during finalist presentations
- 10% - Serves as a clinical liaison between the sales team and Information Technology to assist in the design, development, maintenance, training and evaluation for assigned clinical and business systems or reports to support quality healthcare outcomes. Serves as a clinical liaison between the sales team and Information Technology to assist in the design, development, maintenance, training and evaluation for assigned clinical and business systems or reports to support quality healthcare outcomes
- 10% - Leads and promotes collaboration across CBC functional areas to support sales and organizational clinical initiatives
Skills
- Demonstrated excellent oral and written communication skills.
Knowledge
- Knowledge of current and emerging clinical management practices.
- Knowledge of NCQA, JCAHO and American Accreditation HealthCare Commission/URAC standards.
- Knowledge of Pennsylvania Department of Health and Department of Insurance regulatory requirements, as well as ERISA and other federal regulations affecting health plan administration.
- Ability to perform thorough research taking into account various product variations..
- Ability to perform clinical analysis necessary to translate clinical policies into systems requirements.
- Knowledge of clinical coding including CPT, HCPCS, ICD-9, Revenue Codes and DRG’s.
- Ability to translate clinical concepts into operational needs that can be coded in a systematic manner
- Ability to identify data aberrancies which could reflect incorrect methodologies.
- Ability to identify interventions that could be taken (such as promotion of cancer screenings, wellness programs, maternity management) based on cost and utilization data.
Experience
- Minimum of ten years combined experience in a managed care/health insurance environment and clinical setting.
- Professional experience with population health data reporting, design and analysis for health systems
- Requires clinical practice or clinical informatics related experience that demonstrates an understanding of the tools and concepts used for technical and clinical components of clinical information systems
- A minimum of two years’ experience with BlueCross/Blue Shield benefit coverage and limitations.
- A minimum of two years’ experience working with interrelationships of benefit coverage.
- A minimum of two years’ experience working with managed care offerings and how benefits are to be interrupted, delivered and managed
- A minimum of two years’ experience analyzing medical and prescription drug cost and utilization data
- A minimum of two years’ experience working with normative data by product type and industry
- A minimum of five years’ experience working with care management documentation platforms
Education And Certifications
- Minimum requirements include an RN degree with active license. Masters degree highly desirable.
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.
About Us
We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield 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.
