Clinical Program Manager

Martin's Point Health Care•Portland, ME

2d•Onsite

About The Position

The Clinical Program Manager - Case Management leads strategic initiatives for the Generations Advantage and USFHP lines of business. In this role, you will design, implement, and oversee targeted programs aimed at improving care transitions, reducing avoidable readmissions, and enhancing post-discharge follow-up, while ensuring strict compliance with regulatory requirements. Additionally, you will champion our integrated, whole-person care model by optimizing workflows and operational reporting. Acting as a key resource across the organization, you will collaborate with cross-functional stakeholders to align clinical strategies with operational excellence and ongoing program success.

Requirements

Bachelor’s Degree in Health Science, Nursing or related field required.
10 years’ experience in healthcare including managed care, with a focus in Program Management, overseeing clinical programs and driving process improvement initiatives required.
Experience using data and data analysis to design and monitor programs and manage success, including ROI, of programs required.
Experience in evaluating financial and clinical performance metrics required.
Demonstrated experience with NCQA case management accreditation standards, audit preparations, and HEDIS quality metrics required.
Excellent communication and presentation skills, oral and written.
Strong organizational skills including the ability to work independently and prioritize work.
Competence with computers and business applications; Microsoft Excel, Visio, Word, PowerPoint, Outlook, Access.
Demonstrated track record of driving new clinical programs through implementation and monitoring.
Demonstrated expertise managing teams and multi-disciplinary workgroups in achieving team objectives, without direct authority.
Strong attention to detail and the ability to multitask.
Ability to review, interpret and present information to Health Plan Leadership and external partners.
Ability to lead change and assist in the development of change strategies in support of Health Plan and Organizational goals and objectives.

Nice To Haves

Master's degree in Business Administration (MBA), Healthcare Administration (MHA), or Public Health (MPH) preferred.
Certified Case Manager (CCM) or American Case Management Association (ACMA) certification preferred.
Experience in Medicare Advantage and TRICARE preferred.
Proficiency in health IT systems, including specialized Case Management platforms (e.g., TruCare, Salesforce Health Cloud,), Electronic Health Records (EHRs), and clinical data analytics reporting tools preferred.

Responsibilities

Supports program development activities, including operational reporting and program resources
Translates organizational strategy into actionable, localized case management work plans
Streamlines case management workflows to eliminate clinical inefficiencies and improve member engagement
Optimizes data reporting structures to track program metrics, identifying trends that require clinical interventions
Monitors program benchmarks and key performance indicators (KPIs) to measure the success of CM Program
Ensures all clinical initiatives comply with TriCare, CMS, NCQA, and other state or federal regulatory standards
Identifies trends, gaps and operational risks through performance monitoring
Develops presentations, communication, and program tools in support of CM Program
Partners with cross-functional leaders to align care model and implement new program initiatives
Facilitates committees and working groups to communicate program updates, barriers, and financial outcomes
Collaborates with IT and analytics teams to refine case management software platforms and reporting dashboards and scorecards.
Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.