Program Manager, Clinical Compliance

Blue Cross Blue Shield of Massachusetts•Hingham, MA

4d•$95,490 - $116,710

About The Position

The Medicare Clinical Program Manager focuses on utilization management compliance and CMS audit readiness, including evaluating and supporting Health and Medical Management (HMM) and delegate compliance with CMS regulations and reporting. The role uses analytical, leadership, and organizational skills to perform audits, summarize and communicate findings, conduct gap analyses and risk assessments, manage projects, and collaboratively develop mitigation strategies. As an individual contributor on the HMM Quality and Compliance team, the manager collaborates with and guides HMM teams, company leaders inside and outside HMM, and external delegates to support compliant processes. The role serves as a subject matter resource, builds stakeholder relationships, leads meetings and projects, and supports implementation of regulatory requirements and effective workflows and policies. Other responsibilities may be assigned by the Senior Manager.

Requirements

RN or clinical professional degree with an active Massachusetts clinical license.
Bachelor’s degree required.
3–5 years of clinical experience; inpatient care or medical policy experience is preferred.
3–5 years of utilization management experience at a health plan or equivalent managed care organization.
1–2 years of experience 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, and Federal Employee Plan requirements, including auditing and monitoring corrective action plans.
Strong critical thinking, planning, organization, and time-management skills, including meeting deadlines, problem-solving, and managing competing priorities.
Demonstrated management and leadership skills, including relationship-building, consensus-building, negotiation, influencing, change management, and providing 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, including the ability to navigate, interpret, and analyze utilization management medical management data; proficiency in Care Prominence (MHK), Word, Excel, Adobe Acrobat, PowerPoint, and MS Outlook.
Knowledge of compliance and quality improvement techniques and theory.
High school degree or equivalent required unless otherwise noted above.

Nice To Haves

Inpatient care or medical policy experience.

Responsibilities

Understand CMS regulations and evaluate Medicare utilization management compliance.
Monitor, audit, track, and summarize key findings for audiences at various organizational levels.
Assess and audit medical records and utilization management letters against medical necessity criteria, regulatory criteria, and CMS chapter guidelines.
Review applicable policies and procedures to ensure they are current and comply with CMS requirements.
Lead internal audits to identify risks and opportunities to improve processes, policies, and systems.
Communicate audit findings, risk insights, and recommendations to operational teams and executive leadership.
Serve as a resource and subject matter expert, sharing expertise.
Build credible relationships with stakeholders, provide consultation, and influence decision-making.
Plan and facilitate meetings.
Collaborate with business-area leaders and cross-functional teams to develop, implement, and monitor effective workflows and policies.
Lead projects and work with teams to implement new or updated regulatory requirements.
Perform other responsibilities as assigned by the Senior Manager.