Program Manager, Consultant

Blue Shield of California•San Diego, CA

3d•Hybrid

About The Position

The Program Manager, Consultant, Quality Improvement is responsible for the development and execution of targeted, quality improvement initiatives in support of the Medi-Cal line of business, contributing to improved performance on various quality rating systems including, but not limited to, Healthcare Effectiveness Data Information Set (HEDIS), Managed Care Accountability Set (MCAS), Consumer Assessment of Healthcare Providers and Systems System (CAHPS), National Committee for Quality Assurance (NCQA) Health Plan Ratings, Department of Managed Health Care (DMHC) Health Equity Quality Measure Set (HEQMS), and Medicaid Quality Rating System (QRS). This includes the design, development and management of provider group quality interventions, toolkits, clinic days and gathering analytic insights with the quality data. The Program Manager also has accountability for aligning quality improvement initiatives with other lines of business (Commercial, Medicare) and for ensuring that current and future QI programs align with long-term organizational strategies. In a results-oriented environment, the Program Manager will execute quality improvement efforts, incentive strategies, and new improvement tactics to bring additional value to integrated health benefits. To do this, the Program Manager is expected to coordinate with internal, cross-functional matrix teams, as well as with clinical leadership and staff in provider organizations. The Program Manager will be responsible for participating in project teams and working with external vendors, assigning and monitoring work of team members, and providing guidance and leadership to ensure timely execution of deliverables. This position may include limited accountability for managing budgets. In partnership with the Medi-Cal team, the Program Manager will support in-person clinic days across San Diego County that are held at Community Based Organizations; this may include occasional evening and weekend commitments. The Program Manager will also be accountable for building strong, collaborative relationships with targeted provider organizations. The Program Manager is responsible for developing and managing communications about Blue Shield of California Promise Health Plan quality improvement initiatives through the development of RFI responses, Medi-Cal contracts, toolkits, and other ad hoc assignments. Additionally, this position organizes interdepartmental activities and has some operational responsibilities. 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. This role will be hybrid virtual, where this person will be required to go into the office and/or clinic’s 5 days per month per business need. Clinic days are located in San Diego.

Requirements

Bachelor's degree or equivalent experience required.
At least 7 years of experience in related areas.
Minimum of 7 years of health plan experience.
7 years' experience with quality improvement/process improvement/practice transformation techniques required.
At least 5 Years of Medicaid/Medi-Cal experience required.
5 years of experience working with IPAs, medical groups, FQHCs, and/or providers required.
Previous project/program management experience required.

Nice To Haves

Master's degree or clinical licenses preferred (RN, LVN).
Knowledge of HEDIS and accrediting body requirements (e.g., NCQA) desired.
Proficiency with Cozeva application is highly desired.
Tableau for quality reporting is preferred.
Experience with review of medical records to identify service compliance and missed opportunities preferred.
Experience in the CA delegated model or with highly integrated clinical delivery systems preferred.

Responsibilities

Responsible for planning, execution, and evaluation of large and complex program initiatives to improve quality performance in the Medi-Cal line of business.
Develops and monitors measurement strategies for large change and improvement initiatives.
Manages program(s) from initiation/pilot phase through delivery/spread and monitors for continuous improvement.
As part of a broader QI team, it influences the business unit, strategies, and objectives.
Becomes an expert in company quality initiatives, as well as the products, functions, marketing, and/or service policies and procedures that support those initiatives.
Serves as a quality expert with internal constituents to drive successful improvement initiatives in the Medi-Cal line of business.
Leads and supports interventions to improve performance on HEDIS, MCAS, CAHPS, NCQA Health Plan Ratings, DMHC HEQMS, and Medicaid QRS.
Supports in-person community-based clinic days at Community Based Organizations in San Diego County (2-3 days a month or as scheduled)
Educates and works with external partners and participating practices as needed to identify innovation opportunities and adopt improvement actions.
Partners with providers, in-person, at clinic locations to identify practice barriers and areas for improvement.
Exercises independent judgment in developing methods, techniques, and evaluation criteria for obtaining results.
May assist in the planning and direction of budgets.
May act as the business unit liaison to corporate initiatives and projects.