Senior Clinical Consultant

Become a part of our caring community and help us put health first
 The Senior Provider Contracting Professional initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements for an organization that provides health insurance. The Senior Provider Contracting Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Senior Provider Contracting Professional will be accountable to:

• Communicate effectively and act as a strategic intermediary between the Markets (multiple levels of leadership) and the Clinical Contracting Support Team with the Medicare Markets
• Collaborate with Market contracting organizations to identify opportunities for clinical solution implementations; engage the correct SMEs in appropriate dialogues
• Partner directly with Clinical and non-Clinical teams from across the organization leadership on the execution of the above activities, as well as in the identification of potential new opportunities
• Assist in the creation of scalable, repeatable, compliant, and standardized implementations of UM Processes
• Assist in the development, iteration, launch and utilization of tools/tracking mechanisms
• Assist in the identification, creation, value assessment, compliant clinical programs aimed at reducing provider abrasion instances without having to agree to contract concessions terms
• Provide clinical data reporting for various contract themes and financial impacts to the enterprise.
• Deliver on a wide range of strategic and tactical activities, including contracting/business development, capability definition and advancement, organizational level strategy, market level opportunities, and partnership on related activities as part of a matrix environment
• Convert strategy/tactical priorities into business cases and initiatives while prioritizing timelines and ensuring consensus and execution
• Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Make decisions regarding own work methods, occasionally in ambiguous situations, and require minimal direction
• Follows established CMS, Humana Policy guidelines, and compliance procedures

Responsibilities will include, but not be limited to the following:

• Collaborate with Markets, National Provider, and Interoperability teams to drive electronic connectivity and to support clinical processes and alternatives to ALC Alternative Level of Care (ALC) Front End Review (FER) Exclusions, and Independent Review Organization(IRO) language concessions
• Guide or consult to optimal performance of clinical/quality metrics
• Drive clinical solutions to solve for provider abrasion (non-contractual solutions, UM clinical levers, discharge planning, etc.)
• Implement, manage, and support contractual Utilization Management & other clinical operations

Use your skills to make an impact
 

Required Qualifications

• Bachelor’s degree in professional or healthcare related field
• Five (5) …