We are seeking an experienced Industry Consultant in Healthcare Payer domain with SME knowledge in Care Management and Utilization Management. This role will play a critical part in managing Care Radius application for a healthcare client and will directly support the successful execution of multiple complex initiatives planned for this application.
A career in IBM Consulting is built on long-term client relationships and close collaboration worldwide. You’ll work with leading companies across industries helping them shape their hybrid cloud and AI journeys. With support from our strategic partners robust IBM technology and Red Hat you’ll have the tools to drive meaningful change and accelerate client impact. At IBM Consulting curiosity fuels success. You’ll be encouraged to challenge the norm explore new ideas and create innovative solutions that deliver real results. Our culture of growth and empathy focuses on your long-term career development while valuing your unique skills and experiences.
In this role you'll work in one of our IBM Consulting Client Innovation Centers (Delivery Centers) where we deliver deep technical and industry expertise to a wide range of public and private sector clients around the world. Our delivery centers offer our clients locally based skills and technical expertise to drive innovation and adoption of new technology.
• Serve as a domain SME for the Care Radius application supporting end-to-end development enhancements and issue resolution.
• Collaborate closely with business stakeholders across Utilization Management Care Management and Provider Operations to translate requirements into functional and technical solutions.
• Drive improvements across workflows related to Authorizations Referrals Appeals Grievances Case Management and Enrollment.
• Provide guidance on JCS and JEDI rules engine configurations to ensure accurate and efficient processing.
• Analyze claims membership and provider data flows to support system optimization and defect resolution.
• Partner with cross-functional teams including development QA architecture and operations to deliver high-quality product releases.
• Contribute to roadmap planning for upcoming Care Radius initiatives by bringing deep industry insights and application knowledge.
• 7 to 10 years of experience in the U.S. healthcare payer industry with strong domain knowledge across Commercial Medicaid Medicare and Braven Health lines of business.
• Extensive hands-on experience with Care Radius including workflows for Utilization Management and Care Management.
• SME-level understanding of JCS and JEDI rules engines.
• Proven ability to work with business and operational teams on authorizations appeals grievances referrals and enrollment processes.
• Strong analytical skills with exposure to claims membership and provider data flows.
• Technical hands-on experience on TCL and Javascript with the ability to collaborate effectively with technical development teams.
• Basic technical knowledge of Java and SQL
• Proficient in CICD development and deployments using Jenkins and Bitbucket
• Experience in contributing to complex multi-phase platform enhancement programs.
• Ability to mentor teams and act as a bridge between business SMEs and technical groups.