Strategy Consultant Utilization Management and Medical Policy

JOB SUMMARY

We are seeking a highly tactical and data-fluent Strategy Consultant to drive change within our Utilization Management and Medical Policy this role you will bridge the gap between clinical decision-making and operational finance. You are a doer who can take a defined strategic goal determine the tactical steps to achieve it and get your hands dirty building the data models to prove it out. You will operate with a high degree of self-sufficiency manipulating standardized healthcare data assets to build business cases track administrative costs and project future performance.

Key Responsibilities

• Develop Financial & Operational Models: Build and implement robust data models to evaluate medical policy and utilization management strategies quantify financial and operational impacts and measure actual performance against expected outcomes
• In the First 90 Days: Lead the development of a foundational model accounting for cost savings and administrative costs at a procedure-code level for our prior authorization list including trend analysis and future projections.
• Perform Hands-On Data Manipulation: Extract and transform data from centralized IT/data offerings to create a fit-for-purpose data layer conducive to analyses.
• Cross-Functional Collaboration: Partner with data engineering teams to secure necessary data assets and translate those technical assets into actionable insights for clinical and operational stakeholders.
• Execute Tactical Strategy: Work within leaderships strategic boundaries to independently define and execute the day-to-day tactical steps required to achieve high-level goals.

This is a remote based role however we would like someone close to Pittsburgh PA

ESSENTIAL RESPONSIBILITIES

• Work with business/ market owners to identify key business issues apply right analytical framework develop solution and recommendations represent findings to stakeholders and own the outcome.
• Manage major strategy projects with the help of internal or external strategy consulting resources.
• Serve as subject matter expert to Strategic Operations staff and stakeholders on membership growth and operational strategy issues.
• Provide periodic informal work guidance/direction to junior team members; Provide performance input and recommendations to management for development/ training plans. May have supervisory responsibilities on a project basis.
• Develop analytical frameworks approach and methodology best practices to analyze strategy issues.
• Other duties as assigned or requested.

EDUCATION

Required

• Masters Degree in Business Healthcare Economics or related degree
• 2 years of post-grad experience with strategy / management consulting firms (such as McKinsey Boston Consulting Group Booz & Company Accenture (strategy Practice) or Deloitte (Strategy practice) ) or internal strategy groups of healthcare companies (such as Aetna United Health Group WellPoint GE )
• 6 years of related experience in Business or Healthcare

Substitution

• Bachelors degree and 3 years of relevant progressive strategic experience in lieu of Masters degree

Preferred

• Experience: 35 years in healthcare strategy healthcare economics clinical analytics or a related consulting role focused on tactical execution.
• Technical Data Skills: Highly proficient in data manipulation and modeling (e.g. advanced SQL Python/R or complex Power BI/Tableau builds). Note: We are not looking for a data architect but rather a strategist who is technically self-sufficient.
• Healthcare Domain Expertise: Deep understanding of healthcare financial and operational datasets (claims procedure codes cost-of-care).
• Clinical Context: Working knowledge of Utilization Management Medical Policy and clinical terminologies (EHR ICD-10 interoperability standards).
• Translation & Communication: Proven ability to collaborate with highly technical data teams and present compelling data-backed operational changes to clinical leaders.

LICENSES or CERTIFICATIONS

• None

Preferred

• None

SKILLS

• Broad application of principles theories and concepts in strategic thinking plus working knowledge of other related fields
• Strong PC application Skills (MS Office including PowerPoint and Excel)
• Knowledge of healthcare industry trends and challenges
• Strong critical thinking skills
• Good communication and presentation skills

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Remote

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Never

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Never

Lifting: 25 to 50 pounds

Never

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties responsibilities and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities employees may have access to covered information cardholder data or other confidential customer information that must be protected at all connection with this all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Companys Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore it is every employees responsibility to comply with the companys Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws rules and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidates qualifications experience and expected contributions as well as internal peer equity market and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal state or local law.

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