Sr. Program Manager, Clinical Quality

Blue Cross and Blue Shield of Massachusetts, Inc.; Golden Horseshoe; Hybrid; USD 117,000 - 145,000; Full time

Job summary

An established industry player is seeking a Sr. Program Manager to lead clinical quality initiatives. In this pivotal role, you will drive accreditation compliance, manage cross-functional projects, and collaborate with various departments to enhance quality improvement efforts. With a focus on evidence-based practices, you will engage stakeholders, analyze data, and implement innovative solutions to advance healthcare quality. This position offers a flexible work arrangement, allowing you to thrive in a supportive environment while making a significant impact in the healthcare sector.

Benefits

Paid Time Off

Health Insurance

401(k)

Well-being Benefits

Qualifications

• 6+ years of clinical and managed care experience with supervisory roles.
• Experience in quality improvement or compliance management related to NCQA standards.

Responsibilities

• Support organizational commitment to quality and engage stakeholders.
• Collect, analyze, and validate data for quality initiatives.

Skills

Clinical Quality Improvement

Data Analysis

Project Management

Leadership

Negotiation

Care Management Processes

Education

Registered Nurse (RN)

CPHQ or similar certification

Tools

CQI Tools

Job description

Ready to help us transform healthcare? Bring your true colors to blue.

The Role

The Sr. Program Manager, Clinical Quality is responsible for developing, managing, coordinating, and contributing to numerous Health and Medical Management (HMM) cross-functional projects by establishing and maintaining a system that evaluates the quality of member care. These projects include supporting Case Management program design and quality improvement initiatives as a consultant for NCQA accreditation standards, including monitoring for risks and improvement opportunities. The role also serves as a resource regarding accreditation standards, including NCQA standards and continuous quality improvement principles.

This role drives the implementation of divisional accreditation requirements, prepares documentation for accreditation submissions, provides delegation oversight, and evaluates opportunities for improvement related to clinical program and accreditation compliance. It involves influencing and collaborating with departments, external delegates, and team members to lead or support corporate initiatives. The role may also coordinate accreditation activities on behalf of the organization.

The Team

Under the direction of the Director of Clinical Quality, the Sr. Program Manager collaborates with Clinical Quality team members on quality performance initiatives.

Key Responsibilities:

1. Supports organizational commitment to quality, engages stakeholders, and provides consultation to QI structures and committees. Evaluates and integrates quality innovations, promotes population health management, and leads change using evidence-based practices.
2. Collaborates within HMM and with outside partners, including Performance Measurement and Improvement, Network Management, and Contracting, to advance quality and accreditation goals.
3. Uses CQI tools to facilitate improvement based on evidence-based principles.
4. Collects, analyzes, and validates data for quality initiatives and presents findings internally and externally.
5. Evaluates compliance with NCQA standards and other relevant regulations.
6. Manages collaboration with Operational Business Partners to drive improvements, develop policies, monitor compliance, and communicate risks.
7. Provides oversight of relevant delegates.
8. Shares expertise through educational opportunities to improve quality culture and skills within HMM.

Key Qualifications:

1. Strong understanding of clinical quality improvement principles and techniques, with the ability to develop collaborative initiatives.
2. Ability to review, interpret, and communicate data effectively, supporting analysis and improvement interventions.
3. Experience managing multiple projects from inception to evaluation.
4. Leadership skills including consensus building, negotiation, and change management.
5. Excellent organization and time management skills to meet deadlines and handle multiple priorities.
6. Knowledge of care management processes and systems is a plus.

Education and Experience

1. Typically requires an RN with six or more years of clinical and managed care experience, including supervisory experience.
2. 3-5 years' experience in quality improvement or compliance management related to NCQA, CMS, or similar standards, with experience in audits.
3. Strong project management skills; CPHQ or similar certification is a plus.

This position is eligible for a flexible work arrangement with in-office expectations for local candidates, typically 2 days per week, subject to business needs.

Additional Details

Location: Boston, Hingham

Time Type: Full time

Salary Range: $117,900 - $144,100

Benefits include paid time off, health insurance, 401(k), and well-being benefits.

Why Blue Cross Blue Shield of MA?

We value diversity and inclusion, encouraging candidates to bring their true colors, perspectives, and experiences. We are committed to your development and creating a supportive, inclusive workplace. Learn more about our culture and opportunities by visiting our Company Culture page and joining our Talent Community.

We believe in wellness and work/life balance. For more information, visit our "How We Work" page.