Senior Business Consultant; Remote

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This position will play a pivotal role in the modernization and redesign of the utilization management department within the Health Services division. The Senior Business Consultant provides expertise in tailored, strategic, and critical work to help design, launch, and execute programs that support initiatives in the changing healthcare industry. Using a deep understanding of utilization management, the Senior Business Consultant acts as a liaison between the UM clinical teams, the technical support teams, and the claims operations teams.

The incumbent will be expected to maintain alignment of authorization to claims processing using claims system configuration, including claims edits, and will have deep knowledge of plan design across all commercial and government programs. This role is remote, with periodic onsite visits to Care First locations for meetings, training, and other business‑related activities.

• Provide subject‑matter expertise in utilization management workflows and technology platforms, project management, finance and budget, data and metrics, and information technology.
• Collaborate on business strategy, program development, and identification of strategic opportunities, driving automation and efficiency for UM teams.
• Lead cross‑functional teams and projects across divisions and among internal and external stakeholders to deliver value to the utilization department and Health Services division.
• Identify synergies and mutually reinforcing work streams across business functions to accomplish initiatives more effectively.
• Assist in developing, standing up, and operationalizing technology platforms to track progress, programs, and impact for supported service areas.
• Design and run dashboards to support clear communication across vertical components of business.
• Review and support task coordination while identifying potential process improvements.
• Develop and finalize budgets, policies, and other documentation for programs.
• Build trusted relationships within and across Care First to deepen subject‑matter expertise, synchronize efforts, and ensure close coordination with teams in their areas of responsibility.
• Communicate strategy, programs, and next steps to leadership and key stakeholders.

Education Level: Bachelor’s Degree or equivalent via 4 years of relevant work experience.

Experience: Minimum 10 years in business development, operational technology support, general business operations, and/or consulting.

• Deep understanding of utilization management and claims system configuration to ensure alignment of authorization to claims processing.
• Experience with plan design across commercial and government programs and administration in a large payer organization.
• Knowledge of Guiding Care, Facets, and other key systems to explore automation and efficiency opportunities.
• Ability to collaborate across multiple business areas and with clinical, medical director, and other stakeholders.
• Experience using change management principles in clinical and clinical support operations.
• Professional communication skills and capability to lead conversations and meetings.

• Understanding of business goals and priorities.
• Awareness of evolving market, industry, and consumer trends.
• Effective verbal and written communication of complex ideas.
• Exceptional project management, facilitation, and organizational skills.
• Excellent relationship management.
• Strategic thinker, problem solver, and collaborator.
• Proficient with MS Office (Excel, PowerPoint, Word).
• Strong analytic skills utilizing tools such as Power BI and Excel.
• Ability to meet deadlines, manage multiple customer service demands, and provide positive customer service to all internal and external customers.

$120,000 - $214,500

Clinical Utilization Management

Care First Blue Cross Blue Shield is an Equal Opportunity (EEO) employer. The Company commits to…