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Clinical Insights Specialist

2 months ago

Harrisburg Pennsylvania, United States Capital Blue Cross Full time
Position Overview:

Capital Blue Cross is seeking a highly skilled Clinical Insights Specialist to provide clinical expertise and support to our sales and account management team. This role will involve analyzing data to improve health plan performance and collaborating with other departments to prepare for client meetings and provide responses to client requests.

Key Responsibilities:
  • Coordinate and facilitate data analysis for client meetings
  • Provide clinical consultation based on analysis and identification of key drivers of results
  • Facilitate weekly/monthly clinical and financial status reports for strategic accounts
  • Provide ad hoc clinical summaries and conduct research of claims and relay clinical implications of care rendered for members with likelihood of future healthcare costs
  • Maintain relationships with employer groups, brokers, and coalitions to support sales efforts
  • Serve 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
  • Lead and promote collaboration across CBC functional areas to support sales and organizational clinical initiatives
Requirements:
  • Demonstrated excellent oral and written communication skills
  • 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
About Us:

At Capital Blue Cross, we recognize that work is a part of life, not separate from it. We foster a flexible environment where your health and wellbeing are prioritized. 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.