Medicare Clinical Compliance Program Lead

Blue Cross Blue Shield of Massachusetts; Hingham (MA); On-site; USD 95,000 - 117,000; Full time

Benefits offered by this job

Comprehensive benefits package

Paid time off

Medical/dental/vision insurance

401(k)

Well-being benefits

Job summary

Blue Cross Blue Shield of Massachusetts is hiring a Medicare Clinical Program Manager in Hingham, MA to oversee utilization management compliance and CMS audit readiness. The role focuses on evaluating CMS regulations, performing audits, and communicating findings to leadership while guiding mitigation actions.

The position requires strong analytical, leadership, and project management skills, with experience in regulatory standards (NCQA, MA/RI regulations) and utilization management.

Qualifications

• RN or clinical professional degree with active Massachusetts clinical license with 3–5 years of inpatient care or medical policy experience.
• Bachelor’s degree required.
• 3–5 years of Utilization Management experience at a health plan or equivalent managed care organization.
• 1-2 years experience of managing people or projects.
• 2-5 years of experience working with utilization management regulatory and accreditation standards, such as NCQA, Massachusetts and Rhode Island regulations, Federal Employee Plan, including auditing and monitoring corrective action plans.

Responsibilities

• Understand CMS regulations and evaluate Medicare utilization management related compliance including monitoring and summarizing key findings across the organization.
• Lead internal audits that identify risks and areas for improvement in processes, policies, and systems.
• Communicate audit findings, risk insights, and recommendations to diverse audiences, from operations to executives.
• Act as a subject matter expert and share expertise with stakeholders.
• Build relationships to engage stakeholders and influence decisions.
• Lead meetings with effective planning and facilitation.
• Collaborate with cross-functional teams to develop and monitor compliant workflows and policies.
• Lead projects and implement new or updated regulatory requirements.
• Other responsibilities as assigned by the Senior Manager.

Skills

Critical thinking

Leadership

Communication

Project management

CMS regulations

Data analysis

Care Prominence (MHK)

Education

RN license (MA)

Bachelor’s degree

Tools

MS Word

Excel

PowerPoint

Adobe Acrobat

MS Outlook

Care Prominence (MHK)

Job description

Blue Cross Blue Shield of Massachusetts is hiring a Medicare Clinical Program Manager in Hingham, MA to oversee utilization management compliance and CMS audit readiness. The role focuses on evaluating CMS regulations, performing audits, and communicating findings to leadership while guiding mitigation actions.

The position requires strong analytical, leadership, and project management skills, with experience in regulatory standards (NCQA, MA/RI regulations) and utilization management.