Program Manager, Clinical Compliance

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

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

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, so we encourage you to bring your true colors, perspectives, and 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. If this sounds like something you’d like to be a part of, we’d love to hear from you.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our How We Work Page.