Program Manager, Clinical Compliance

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

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

The Role

The Medicare Clinical Program Manager will focus on utilization management compliance and CMS audit readiness activities such as evaluating and supporting Health and Medical Management’s (HMM) and delegate’s CMS regulations and reporting. 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, project management, and collaboratively develop mitigation strategies.

The Team

As an integral part of HMM Quality and Compliance team, the Medicare 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

• 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.

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.
• Ability to work autonomously and drive initiatives to successful and timely completion.
• 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.
• Knowledge of compliance and QI techniques and theory.

Education and Experience

• 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.

Minimum Education Requirements

High school degree or equivalent required unless otherwise noted above.

Location

Hingham

Time Type

Full time

Salary Range

$95,490.00 - $116,710.00

Compensation Overview

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 the confidence gap and imposter syndrome can prevent amazing candidates coming our way. 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 our Company Culture page. For more information on how we work and support that work/life balance visit our "How We Work" Page. Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance. Blue Cross Blue Shield of Massachusetts is an Equal Employment Employer - veterans/disability. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law. Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.