Program Manager, Clinical Compliance

Blue Cross Blue Shield of Massachusetts • Hingham, MA

21h • Hybrid

About The Position

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.

Requirements

• 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
• 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.

Nice To Haves

• Inpatient Care or medical policy experience preferred

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

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 1,001-5,000 employees