Program Manager, Clinical Compliance

The Role:
The Medical Clinical Program Manager will focus on utilization management compliance and audit readiness activities such as evaluating and supporting Health and Medical Management's (HMM) and delegate's compliance with the applicable NCQA utilization management standards and state and federal regulations.

This position leverages analytical, leadership and organizational skills to perform audits, summarize and communicate findings to various levels in the organization, perform gap analysis, risk assessment, track issues/ risks to closure, and collaboratively develop mitigation strategies. Other NCQA accreditation work includes delegation oversight and preparing documentation for accreditation submission.

The Team:

As an integral part of HMM Quality and Compliance team, the Clinical Program Manager works through the influence as an individual contributor while collaborating and providing guidance to HMM teams, company leaders within and outside of HMM, and to external delegates to achieve compliant processes.

Key Responsibilities:

• Evaluate NCQA, Rhode Island, & Massachusetts utilization management related compliance including:

• Monitor, audit, gap identification, analysis, and summary of key findings to various levels in the organization
• Apply their clinical knowledge when assessing/auditing medical records and UM letters against medical necessity criteria and accreditation and regulatory criteria
• Collaborating with operational leaders/ delegates to mitigate/ improve compliance
• Standing up new NCQA standards or regulatory requirements
• Review applicable policies and procedures to ensure all are up to date and reflect the appropriate compliance with regulatory and compliance requirements

• Perform delegation oversight activities in accordance with NCQA standards, Regulatory standards, and BCBSMA standards
• Plan and scope deliverables with minimal support; keep project/ workgroup leads and Director informed of key issues/ risks and meet deadlines
• Collaborate with Director and Senior Program Managers to identify/ implement workflows and process improvements to maximize quality, efficiency, and cost effectiveness of team
• Represents department on cross functional workgroups and projects as a subject matter expert (SME) and sharing expertise with teammates, HMM associates, and leaders
• Other responsibilities as assigned by the Director

Key Qualifications:

• Strong critical thinking, planning, organization, and time management skills including the ability to meet deadlines, problem solve, and manage multiple competing priorities
• Demonstrated management and leadership skills including building trusting and credible relationships & consensus building, negotiating, influencing, the ability to manage change, and provide constructive feedback
• Strong written communication, meeting facilitation, and presentation skills
• Strong computer skills: ability to navigate, interpret, & analyze information from the utilization management medical management data as well as proficient in Care Prominence (i.e. MHK), Word, Excel, Adobe Acrobat, PowerPoint, and MS Outlook.
• Working knowledge of NCQA UM accreditation requirements, Massachusetts, and Rhode Island utilization review regulations
• Knowledge of compliance and QI techniques and theory

Education and Experience:

• Active and Unrestricted State Clinical License required
• Bachelor's degree required
• 3-5 years direct clinical experience required. Inpatient care or medical policy experience preferred.
• 3 years of Utilization Management experience at a health plan or equivalent managed care organization
• 3-5 years of experience working with utilization management regulatory and accreditation standards, such as NCQA, Massachusetts utilization review regulations, Rhode Island utilization review regulations, Federal Employee Plan, including experience with auditing and monitoring corrective action plans.

We are open to reviewing candidates with varying amounts of Compliance experience. Please note, anyone who applies that does not have the required 3-5 years of UM compliance experience may be reviewed for a different job level and salary range.

This position is eligible for the Flex persona, with in office expectations for local candidates 2 days per week. This may change depending on business needs.

#LI-HYBRID

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.