Job Description

Role Purpose

A Medicare domain consultant is a healthcare professional with deep expertise in Medicare regulations, policies, and procedures who advises clients, such as healthcare providers, payers, or technology companies, on optimizing their operations related to Medicare programs, including patient eligibility, billing practices, compliance, and benefit design, to maximize efficiency and revenue while adhering to Medicare guidelines.

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Qualifications

• A bachelor’s degree in health care administration, Public Health, Population Health, Finance, Business Analytics or related field and/or equivalent experience
• 10+ years’ experience of work in Healthcare Payer experience and systems.
  • 10+ years of experience in healthcare analytics, strategy, and/or consulting at an IPA or health plan level, required
  • Good understanding of Medicare, Medicaid and other government healthcare programs. Experience with Eligibility, Enrollment and Revenue Reconciliation is highly preferred.
  • Demonstrated expertise in a variety of concepts, practices, and procedures applicable to utilization management, care management functional areas
  • 5+ years of health plan experience, highly desired
  • Three or more years of recent experience in risk adjustment
  • Strong understanding of risk adjustment operations and V28 payment model and condition categories
  • Knowledge of HIPAA regulations
  • Knowledge of Medicare Advantage, STARS/HEDIS program, and NCQA technical specifications, a plus
  • Knowledge and understanding of ICD-10, CPT and CPT (II), and HCPCS, a plus

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• Project management and program management experience
• You will need to be competent with computers and healthcare applications.  
• You will need to keep up to date with current healthcare literature.
• Present strong skills in analysis and presentation.
• Be able to communicate well verbally and in written form to people from different backgrounds. 
• Excellent interpersonal skills to build relationships with clinical and non-clinical personnel
• Strong analytical and creative problem-solving skills
• Ability to analyze issues / errors reported by customer and perform first level of analysis before handing over to technical teams.
• Act as the single point of contact for clients, manage stake holders and customer expectations, and facilitate resolution of issues.
• Basic understanding of Databases, with hands on experience in writing queries and analyze data files, if required to aid analysis and support activities (mandatory)
• Proactively manage Client needs by understanding business requirements, criticality of issues, ensuring timely updates and maintain customer satisfaction.
• Experience in conducting Product demonstrations and End user training.
• Experience in SAFe Agile and Jira.