Program Manager, Clinical Compliance

Blue Cross Blue Shield of Massachusetts•Hingham, MA

About The Position

Ready to help us transform healthcare? Bring your true colors to blue. The Role: The Clinical Compliance Program Manager will focus on utilization management compliance and audit readiness activities such as evaluating and supporting Health and Medical Management’s (HMM) and delegate’s compliance with the applicable NCQA utilization management standards and state and federal regulations. 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, track issues/ risks to closure, and collaboratively develop mitigation strategies. Other NCQA accreditation work includes delegation oversight and preparing documentation for accreditation submission. The Team: As an integral part of HMM Quality and Compliance team, the Clinical Compliance 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

Ability to work autonomously and drive initiatives to successful and timely completion through well-developed critical thinking, planning, organization, and time management skills
Demonstrated leadership skills including building trusting and credible relationships & consensus building, negotiating, influencing, the ability to manage change
Strong written communication, meeting facilitation, and presentation skills
Ability to navigate Care Prominence UM system, interpret, & analyze data; Proficient in Word, Excel, Adobe Acrobat Pro, PowerPoint, AI, and Outlook
Working knowledge of NCQA UM accreditation requirements, Massachusetts, and Rhode Island utilization review regulations
Working knowledge of compliance and quality improvement techniques
RN or clinical professional degree with active Massachusetts clinical license with 3-5 years of clinical experience
Bachelor’s degree required
3 years of Utilization Management experience at a health plan; Medical Surgical or Pharmaceutical utilization management or clinical experience preferred
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, or CMS including experience with auditing and monitoring corrective action plans.

Responsibilities

Evaluate NCQA, Rhode Island, & Massachusetts utilization management related compliance including:
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
Apply their clinical knowledge when assessing/auditing medical records and UM letters against medical necessity criteria and accreditation and regulatory criteria
Implement new NCQA standards or regulatory requirements
Ensure policies and procedures are up to date and reflect the appropriate compliance with regulatory and accreditation requirements
Perform delegation oversight activities
Represents department on cross functional workgroups and projects as a subject matter expert (SME) and sharing expertise with teammates, HMM associates, and leaders
Collaborate with leaders to identify/ implement workflows and process improvements to maximize quality, efficiency, and cost effectiveness
Other responsibilities as assigned by the Director