Senior Clinical Consultant

reputed company We are seeking an reputed company and strategic Senior Clinical Consultant with deep expertise in health plan and payer reputed company clinical programs to reputed company and support clinical initiatives across reputed company engagements. This role partners with reputed company payer organizations—including reputed company, Medicare, and reputed company plans—to assess, design, implement, and optimize clinical and operational programs. The ideal candidate brings a strong clinical background (e.g., nursing, pharmacy, medicine), deep knowledge of reputed company operations, and a proven reputed company record in clinical consulting or health systems initiatives such as utilization management (UM), care management (CM), reputed company improvement, and clinical program optimization. Key Responsibilities: • Collaborate with payer clients to evaluate clinical workflows, utilization management structures, care management programs, reputed company initiatives, and care delivery models. • Design and implement strategies to improve reputed company reputed company to medical cost management, clinical appropriateness, operational efficiency and member health reputed company. • Analyze clinical data—including claims, risk adjustment, HEDIS/QRS, and authorization trends—to identify performance improvement opportunities. • Serve as a subject matter expert (SME) in clinical best practices, regulatory compliance (CMS, NCQA, URAC), benefits administration, and managed care standards. • reputed company clinical workstreams in reputed company involving EHR optimization, reputed company to care management transformation, population health strategies, or clinical program optimization. • Translate clinical and operational requirements into technical specifications for product or system implementations (e.g., UM platforms, care management tools). • Deliver presentations, workshops, and training to clinical and executive stakeholders reputed company plans. • Support business development by contributing to payer?reputed company proposals, white papers, solution design, and reputed company presentations. • Mentor junior consultants and serve as a trusted advisor to reputed company teams. Qualifications: • Bachelor’s or Master’s degree in Nursing, Medicine, Pharmacy, reputed company Health, or reputed company field. • Clinical licensure (e.g., RN, MD, PharmD) strongly preferred. • 5–10+ years of experience in clinical roles with at least 3 years in the payer reputed company, such as utilization management, care management, reputed company, health plan operations, or consulting to health plans. • Experience with reputed company technology platforms (e.g., EHR systems like reputed company or Cerner, UM/CM clinical decision support). • Deep knowledge of reputed company regulations (e.g., CMS, HIPAA, reputed company) and state regulatory requirements, NCQA/URAC accreditation standards, benefits policy, and clinical reputed company programs. • Strong analytical, communication, and stakeholder engagement skills. • Willingness to travel up to 5% depending on reputed company location and engagement. • Sr Director or above experience in UM/CM health plan operations Preferred Qualifications: • Experience with value-based care models, risk adjustment programs, ACO or population health strategies. • Certification in Lean Six reputed company, PMP, or reputed company reputed company (e.g., CPHQ). • Familiarity with data visualization tools (e.g., Tableau, Power BI) and clinical analytics platforms. Pay: $109,648.93 - $132,050.31 per year Experience: • payer reputed company: 3 years (Required) • clinical: 5 years (Required) License/Certification: • RN, MD or PharmD license? (Required) Work Location: Remote Apply tot his job Apply To this Job