Sr. Consultant - Commercial Healthcare Expert
Tria Federal is seeking a Senior Consultant – Commercial Healthcare & Managed Care SME to support the Department of Veterans Affairs. The SME will provide senior-level healthcare industry and managed-care expertise to help VA assess, monitor, and improve health-plan operations, provider network performance, clinical quality, reimbursement, access, and care delivery across the community-care environment.
The ideal candidate brings substantial experience in commercial health plans, managed care, payer/provider operations, clinical quality, population health, network performance, value-based care, and healthcare transformation. The candidate will translate industry practices into practical recommendations for the VA environment while recognizing the unique requirements of Government health-plan operations.
Responsibilities:
Provide subject matter expertise on commercial healthcare and managed-care operating models, payer/provider relationships, network performance, access, quality, and healthcare delivery.
Analyze current-state health-plan and community-care operations and identify gaps, risks, inefficiencies, and opportunities for improvement.
Assess provider network performance, access, capacity, quality, utilization, and member/patient experience.
Provide expertise on managed-care models, provider engagement, value-based care, alternative payment models, and healthcare cost/outcome management.
Evaluate clinical quality programs, quality measures, performance trends, and opportunities to improve healthcare outcomes.
Support development of business cases, assessments, white papers, strategic analyses, and executive recommendations.
Translate commercial health-plan and industry practices into recommendations applicable to Government healthcare operations.
Collaborate with providers, clinical leaders, acquisition teams, contracts personnel, data/analytics teams, and other SMEs.
Review and provide SME input to policies, procedures, requirements, performance measures, governance materials, and operational guidance.
Support acquisition, implementation, and operationalization activities involving health-plan and provider-network requirements.
Develop executive briefings, decision papers, risk analyses, and recommendations for senior VA leadership.
Skills & Experience:
8+ years of progressively responsible healthcare, health-plan, consulting, or managed-care experience.
Demonstrated experience within a commercial health plan, managed-care organization, payer, provider organization, or healthcare consulting environment.
Strong understanding of managed-care operations and payer/provider relationships.
Experience with clinical quality, healthcare performance improvement, or population-health initiatives.
Experience analyzing healthcare operations, performance, cost, quality, access, or utilization.
Demonstrated ability to translate industry practices into practical business recommendations.
Strong executive communication, facilitation, and written-product development skills.
Bachelor's degree required; Master's degree in Healthcare Administration, Public Health, Business, Nursing, Clinical/Health Sciences, or related field preferred.
Qualifications:
Medicare Advantage, Medicaid, commercial insurance, or dual-eligible experience.
Provider network management or network adequacy.
Value-based care / alternative payment models.
HEDIS, CAHPS, Stars, NCQA, URAC, CMS quality programs, or similar.
Population health management.
Provider contracting or payer/provider strategy.
VA/VHA/IVC/CCN experience.
PMP, Lean Six Sigma, CPHQ, CPC, or similar.