Program Manager Clinical, Consultant -Cost of Healthcare Analysis

Blue Shield of CA; Springfield Meadows (CA); Hybride; USD 120 000 - 165 000; Plein temps

Résumé du poste

Blue Shield of CA is seeking a Program Manager Clinical, Consultant to lead data-driven cost management initiatives for employer-funded health plans. You will analyze clinical and financial data to identify trends, lead cross-functional projects, and develop presentations communicating insights and recommended actions to stakeholders.

The role emphasizes collaboration with the CMO, with hybrid work and required California licensure.

Qualifications

• Bachelor's degree or HS diploma with relevant experience and licensure requirements.
• 7+ years of prior relevant experience.
• Licensed in CA LVN/RN/NP/PA as applicable.
• Experience with healthcare data and cost-of-care analysis is highly preferred.

Responsabilités

• Analyze clinical and financial data to identify trends and opportunities to improve care and manage costs.
• Lead projects to address cost-reduction opportunities and develop actionable recommendations.
• Develop presentations that clearly communicate insights and recommended actions to stakeholders.
• Facilitate meetings with internal and external stakeholders to drive outcomes.
• Drive improvements in healthcare cost trends through targeted interventions and system-level initiatives.

Connaissances

Healthcare data analysis

Cost of care analysis

Cross-functional leadership

Project management

Data visualization

Stakeholder facilitation

Communication skills

Formation

Bachelor's degree

High School Diploma/GED + 4 years experience

7+ years of prior relevant experience

CA LVN/RN/NP/PA license

Outils

Power BI

Description du poste

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.