Program Manager Clinical, Consultant -Cost of Healthcare Analysis

Blue Shield of California•El Dorado, AR

3d•Hybrid

About The Position

The Commercial CMO Team provides clinical oversight for programs and processes that support members’ health care, reduce costs, and improve quality. The Program Manager Clinical, Consultant (Line of Business) reports to the Director of Program Management, Clinical – CMO. The role analyzes clinical and financial data to identify trends and opportunities to improve care and manage costs for employer-funded health insurance, leads projects addressing those opportunities, and develops presentations communicating clinical insights and recommended actions. The position also facilitates meetings with internal and external stakeholders and drives improvements in healthcare cost trends through direct interventions and broader system-level initiatives. The role provides analysis, leadership, and guidance for a line of business, including identifying opportunities, creating business cases, and implementing initiatives. It requires steady leadership amid uncertainty, change, and aggressive deadlines. The Program Manager leads cross-functional meetings and taskforces, collaborates with analytics, actuarial, quality, and cost-of-healthcare teams, and analyzes high-cost claims, populations, and episodes of care. The position researches and recommends interventions, identifies cost-saving opportunities, monitors emerging healthcare cost drivers, and measures outcomes including savings, quality impacts, operational effectiveness, and member experience. The leadership model emphasizes developing leaders, enabling growth, creative and critical thinking, high-performing teams, effective results, and continuous learning. The role allows employees to work virtually full-time, with office attendance expected based on business need.

Requirements

Bachelor’s degree, or a High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree, and completion of an accredited educational program meeting requirements for an applicable professional license.
At least 7 years of prior relevant experience.
Current California LVN, RN, NP, or PA license.
Strong organizational and/or project management skills and consistent ability to self-start and take ownership of end-to-end taskforce activities.
Excellent written and oral communication skills and 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.

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.
Experience working with employer fully insured and self-insured populations, large group accounts, and multidisciplinary stakeholder groups.

Responsibilities

Provide analysis, leadership, and guidance for a line of business, including opportunity identification, business case creation, and implementation.
Provide steady 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 across stakeholders.
Collaborate with analytics, actuarial, and quality teams to develop, analyze, and distribute reports, and document program activities, interventions, and outcomes.
Perform deep-dive analyses of high-cost claims, vendor-identified populations, and other defined groups, producing case studies, reports, and presentations.
Research and recommend interventions and drive actions to significantly affect 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 healthcare 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 cost drivers, including specialty pharmaceuticals, oncology, behavioral health, specialist utilization, and emergency department utilization, and recommend interventions.
Measure and communicate intervention outcomes, including savings realized, quality impacts, operational effectiveness, and member experience considerations.
Partner with analytics teams to develop, analyze, and distribute reporting.
Liaise with enterprise analytics and cost-of-healthcare groups to compare trends, share knowledge, and measure outcomes.
Organize and lead cross-functional meetings and foster teamwork and collaborative problem-solving across diverse stakeholders.
Facilitate cross-functional taskforces with specific cost-of-healthcare commitments.
Perform other duties as assigned.