Program Manager Clinical, Consultant -Cost of Healthcare Analysis

Blue Shield of CA; San Diego (CA); Híbrido; USD 120.000 - 180.000; Jornada completa

Descripción de la vacante

Blue Shield of CA is seeking a Program Manager Clinical, Consultant (Line of Business) to analyze data, lead cost-improvement projects, and communicate clinical insights. You will facilitate stakeholder meetings and drive targeted actions to improve care and manage employer-sponsored costs.

The role emphasizes leadership, critical thinking, and the ability to influence cross-functional teams while advancing healthcare cost trends through both direct interventions and broader initiatives.

Formación

• Requires a Bachelor's degree or equivalent experience and 4 years of additional relevant experience.
• Requires at least 7 years of prior relevant experience.
• License in California LVN, RN, NP, or PA is required.
• Experience in health care data and delivery system with familiarity in California preferred.
• Strong organizational and project management skills with cross-functional leadership.
• Excellent written and oral communication and ability to facilitate discussions.
• Experience with cost of care analysis, population health outcomes, and program evaluation.

Responsabilidades

• Analyze clinical and financial data to identify trends and opportunities.
• Lead projects to address opportunities and develop clear presentations.
• Facilitate meetings with internal and external stakeholders and drive improvements.
• Influence teams to implement actions and communicate outcomes.
• Work on healthcare cost trend reduction through interventions and system-level initiatives.

Conocimientos

Project management

Data analysis

Written & verbal communication

Power BI

Educación

Bachelor's degree or equivalent experience

Herramientas

Power BI

Descripción del empleo

Your Role

The Commercial CMO Team provides clinical oversight for programs and processes that support members' health care, reduce costs, and improve quality. The Program Manager Clinical, Consultant (Line of Business) reports to the Director of Program Management, Clinical - CMO. In this role, you will analyze clinical and financial data to identify trends and opportunities to improve care and manage costs for employer-funded health insurance, lead projects to address these opportunities and develop presentations that clearly communicate the clinical insights and recommended actions. You will also facilitate meetings with internal and external stakeholders and drive improvements in healthcare cost trends through both direct interventions and broader, system-level initiatives.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Knowledge and Experience

• Requires a Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree and a completion of an accredited educational program that meets the requirements for applicable professional license
• Requires at least 7 years of prior relevant experience
• Requires current California LVN, RN, NP, or PA license
• Prefers familiarity with health care data and the health care delivery system in California; health plan or provider experience strongly desired
• Strong organizational and/or project management skills, consistent ability to "self-start" and take ownership of end-to-end taskforce activities
• Excellent written and oral communication skills, ability to facilitate cross-functional discussions, lead teams through influence to drive actions and outcomes
• Experience in cost of health care analysis, population health outcomes, and/or program evaluation desired
• Expertise in analyzing high-cost claims, episodes of care, and healthcare cost drivers to identify opportunities for medical cost reduction desired
• Ability to review complex claims for payment accuracy, contractual compliance, coordination of benefits, and potential payment integrity issues desired
• Prefers knowledge of provider reimbursement methodologies, including DRG, case rate, per diem, percentage-of-charge, and letter-of-agreement arrangements
• Experience identifying fraud, waste, abuse, upcoding, unbundling, inappropriate billing, and other claim-payment vulnerabilities desired
• Experience performing root-cause analyses of trend drivers and developing business cases for cost-of-care interventions desired
• Strong proficiency using data visualization and analytical tools such as Power BI and other reporting platforms to communicate findings and recommendations
• Experience working with employer fully insured and self-insured populations, large group accounts, and multidisciplinary stakeholder groups

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.