Medicare Compliance Program Manager - UM & CMS Audit

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

Job summary

Blue Cross Blue Shield of Massachusetts in Hingham, MA seeks a Medicare Clinical Program Manager to focus on utilization management compliance and CMS audit readiness. You will evaluate CMS regulations, perform audits, summarize findings, and guide mitigation strategies within Health and Medical Management.

The role requires an RN or clinical professional with MA licensure and 3–5 years UM experience; 1–2 years in people or project management is preferred.

Qualifications

• RN or clinical professional degree with active Massachusetts clinical license and 3–5 years of clinical experience.
• Bachelor’s degree required.

Responsibilities

• Understand CMS regulations and evaluate Medicare utilization management compliance.
• Lead internal audits and communicate findings to stakeholders.
• Collaborate with cross-functional teams to develop workflows and policies.
• Monitor, audit, track and summarize key findings for leadership.
• Act as a subject matter expert and drive regulatory readiness.

Skills

CMS regulations

Audit & risk

Leadership

Communication

Project management

Education

RN or clinical professional degree (MA license)

Tools

Care Prominence (MHK)

MS Office (Word, Excel, PowerPoint)

Adobe Acrobat

Job description

Blue Cross Blue Shield of Massachusetts in Hingham, MA seeks a Medicare Clinical Program Manager to focus on utilization management compliance and CMS audit readiness. You will evaluate CMS regulations, perform audits, summarize findings, and guide mitigation strategies within Health and Medical Management.

The role requires an RN or clinical professional with MA licensure and 3–5 years UM experience; 1–2 years in people or project management is preferred.