Program Manager, Consultant

Blue Shield of California • Rancho Cordova, CA

16h • Hybrid

About The Position

The Behavioral Health Network Management, Healthcare Quality and Affordability (HQA) team is responsible for the development and maintenance of all Behavioral Health provider networks, including vendor relationships necessary to provide our members and clients with access to quality, affordable health care services. The Program Manager, Consultant will report to the Program Manager, Principal. In this role you will support the Behavioral Health Network Management, HQA team and be responsible for investigating and resolving claims issues through detailed root cause analysis, cross functional collaboration, and end to end remediation oversight. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Requirements

• Requires a Bachelor’s degree or equivalent experience
• Requires 7 years of prior relevant experience in Medicare claims processing and regulatory requirements; working with regulatory Behavioral Health (BH) requirements, audit readiness, documentation standards; BH claims analysis, issue investigation, and remediation oversight
• Requires Project Management experience

Nice To Haves

• Behavioral Health (BH) managed care experience of 5 years is preferred
• Experience with regulatory BH claims audits is preferred
• Experience researching BH claims for overpayments and fraud is preferred
• Experience with BH Policy & procedure development and auditing is preferred
• Knowledge of fundamentals of BH provider contracts

Responsibilities

• Operate at a strategic business level to ensure projects/programs are in line with Blue Shield of California (BSC) strategic goals
• Consult with all levels including executive leadership teams, make recommendations, and influence decision-making
• Leverage cross-functional internal and external relationships to drive initiatives forward
• Lead intake, investigation, and resolution of complex Behavioral Health (BH) provider-reported claims issues, including escalations and system enhancement
• Perform detailed root cause analysis of claim processing issues, partnering with Claims Operations, Configuration, Provider Operations, EDI, and other teams to identify underlying drivers
• Manage project initiatives from initiation through delivery and oversight for continuous improvement
• Identify patterns and trends in BH claims issues to inform process improvements, configuration changes, and control enhancements to prevent recurrence

What This Job Offers

• Job Type: Full-time
• Career Level: Principal