Program Manager Clinical, Consultant -Cost of Healthcare Analysis

Blue Shield of California•El Dorado Hills, CA

6d•$111,540 - $188,728•Hybrid

About The Position

The Program Manager Clinical, Consultant supports the Commercial CMO Team, which provides clinical oversight for programs and processes intended to support members’ health care, reduce costs, and improve quality. Reporting to the Director of Program Management, Clinical – CMO, this role analyzes clinical and financial data to identify trends and opportunities to improve care and manage costs for employer-funded health insurance. The position leads projects addressing these opportunities, develops presentations communicating clinical insights and recommended actions, facilitates meetings with internal and external stakeholders, and drives improvements in healthcare cost trends through direct interventions and broader system-level initiatives. The role requires leadership amid uncertainty, change, and aggressive deadlines. It partners with analytics, actuarial, quality, and cost-of-healthcare teams to evaluate claims, utilization, cost drivers, intervention outcomes, and program effectiveness. The position may work virtually full-time, with office attendance as business needs require. The company workplace model generally involves two office days per week for most teams, with arrangements based on business needs and other stated circumstances.

Requirements

Bachelor’s degree, or a high school diploma/GED plus four years of additional relevant experience in lieu of a degree and completion of an accredited educational program meeting applicable professional-license requirements.
At least 7 years of prior relevant experience.
Current California LVN, RN, NP, or PA license.
Strong organizational and/or project-management skills, with the ability to self-start and take ownership of end-to-end taskforce activities.
Excellent written and oral communication skills and the ability to facilitate cross-functional discussions and lead teams through influence to drive actions and outcomes.
Strong proficiency with data visualization and analytical tools such as Power BI and other reporting platforms.
Experience working with employer fully insured and self-insured populations, large group accounts, and multidisciplinary stakeholder groups.

Nice To Haves

Familiarity with California healthcare data and the healthcare delivery system; health plan or provider experience is strongly desired.
Experience in cost-of-healthcare analysis, population health outcomes, and/or program evaluation.
Expertise analyzing high-cost claims, episodes of care, and healthcare cost drivers to identify medical-cost-reduction opportunities.
Ability to review complex claims for payment accuracy, contractual compliance, coordination of benefits, and potential payment-integrity issues.
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.
Experience performing root-cause analyses of trend drivers and developing business cases for cost-of-care interventions.

Responsibilities

Provide analysis, leadership, and guidance for a line of business, including identifying opportunities, creating business cases, and supporting implementation.
Provide leadership amid uncertainty, change, and aggressive deadlines.
Create presentations and manage meeting requests.
Lead cross-functional meetings, foster teamwork, escalate and resolve issues, and promote collaboration and coordination among stakeholders.
Collaborate with analytics, actuarial, and quality teams to develop, analyze, and distribute reports, and document program activities, interventions, and outcomes.
Conduct deep-dive analysis of high-cost claims, vendor-identified populations, and other defined groups; produce case studies, reports, and presentations.
Research and recommend interventions and drive actions to improve healthcare costs.
Review high-cost claims and episodes of care to identify cost-saving opportunities, including site-of-care optimization, inappropriate utilization, claims payment integrity, contractual compliance, and coordination of benefits.
Analyze inpatient admissions, readmissions, specialty drug utilization, and high-cost professional and facility claims to identify trend drivers and develop mitigation strategies.
Identify opportunities for site-of-service steerage, provider network optimization, out-of-network utilization management, care management interventions, and benefit design enhancements.
Monitor emerging healthcare cost drivers, including specialty pharmaceuticals, oncology, behavioral health, specialist utilization, and emergency department utilization, and recommend interventions.
Measure and communicate intervention outcomes, including savings, quality impacts, operational effectiveness, and member experience considerations.
Partner with analytics teams to develop, analyze, and distribute reporting.
Liaise with analytics and cost-of-healthcare groups across the enterprise to compare trends, share knowledge, and measure outcomes.
Organize and lead cross-functional meetings and facilitate collaborative problem-solving among diverse stakeholders.
Facilitate cross-functional taskforces with specific cost-of-healthcare commitments.
Perform other duties as assigned.