Medicare Compliance Program Lead — Audit & UM Strategy

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

Benefits offered by this job

Paid time off

Medical/dental/vision insurance

401(k)

Well-being benefits

Variable pay eligibility

Job summary

Blue Cross Blue Shield of Massachusetts in Hingham seeks a Medicare Clinical Program Manager to drive utilization management compliance and CMS audit readiness. You will conduct audits, assess medical records, and collaborate with HMM teams to mitigate risk and ensure regulatory alignment.

In this role you will communicate findings to executives, lead improvement projects, and partner with cross-functional leaders to implement updated CMS requirements while maintaining high standards of quality

Qualifications

• RN or clinical professional degree with active Massachusetts clinical license with 3-5 years of clinical experience Inpatient Care or medical policy experience preferred
• 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 utilization review regulations, Rhode Island utilization review regulations, Federal Employee Plan, including experience with auditing and monitoring corrective action plans.

Responsibilities

• Understand CMS regulations and evaluate Medicare utilization management related compliance including.
• Monitor, audit, track and summarize key findings to various levels in the organization
• Assess/audit medical records and UM letters against medical necessity criteria regulatory criteria and CMS chapter guidelines
• Review applicable policies and procedures to ensure all are up to date and reflect the appropriate compliance with CMS requirements
• Lead internal audits that identify risks and areas for improvement in processes, policies, and systems
• Communicate audit findings, risk insights, and recommendations effectively to diverse audiences, from operational teams to executive leadership.
• Act as a resource/ subject matter expert and sharing expertise
• Build trusting and credible relationships to engage stakeholders, provide consultation, and influence decision making
• Lead meetings with effective planning and facilitation
• Collaborate with business area leaders and cross-functional teams to develop, implement, and monitor effective workflows and policies
• Lead projects and work with teams on implementing new or updated regulatory requirements
• Other responsibilities as assigned by Senior Manager

Skills

Critical thinking

Leadership

Written communication

Autonomy

Data analysis

MS Office

CMS regulations

Influencing

Education

RN/Clinical degree

Bachelor's degree

Utilization Management

People management

Regulatory standards

Tools

Care Prominence (MHK)

MS Outlook

Job description

Blue Cross Blue Shield of Massachusetts in Hingham seeks a Medicare Clinical Program Manager to drive utilization management compliance and CMS audit readiness. You will conduct audits, assess medical records, and collaborate with HMM teams to mitigate risk and ensure regulatory alignment.

In this role you will communicate findings to executives, lead improvement projects, and partner with cross-functional leaders to implement updated CMS requirements while maintaining high standards of quality