Program Manager, Medicaid (Hybrid)

CareFirst•Baltimore, MD

1d•Hybrid

About The Position

Drives Medicaid Risk Adjustment performance through oversight of key operational processes, performance monitoring, analytics, and strategic initiatives. Identifies trends, opportunities, and performance gaps; develops and implements improvement strategies; and communicates results to stakeholders by translating operational performance into measurable business and financial outcomes. Collaborates across departments to support organizational objectives, improve risk-adjusted revenue, optimize forecasting accuracy, and enhance overall program effectiveness. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

Requirements

Bachelor's Degree in Business Management or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
8 years project management or program management experience.
Ability to synthesize large complex data and analysis into clear, concise, executive level presentations that allow for rapid grasp of business problem or opportunity and understanding of feasible solutions.
Effective understanding of how functions integrate within the division and the strategic concept behind the corporate goals.
Ability to translate business needs as it relates to technology, systems, and vendor platforms.
Ability to identify and shepherd strategic opportunities that have a significant impact on the organization.
Ability to establish working relationships and influence/persuade across all levels of leadership including C-Suite.
Knowledge and discipline of Process Improvement.
Use of Microsoft Applications.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Must be eligible to work in the U.S. without Sponsorship.

Nice To Haves

Certified Project Management Professional (PMP)-PMI.
Master's Degree
Project Management Professional Certification (PMP)
8+ years in managing Medicaid risk adjustment programs and provider incentives
5+ years in value-based care for Medicaid
5+ years in Provider Engagement or Provider Enablement in Medicaid
5+ years in Adjusted Clinical Groups (ACG) model management

Responsibilities

Analyzes aggregate Medicaid Risk Adjustment performance across the line of business, leveraging available reporting, operational metrics, and financial results to identify trends, risks, performance gaps, and improvement opportunities.
Conducts detailed analyses to understand performance drivers related to risk score performance, encounter completeness, diagnosis prevalence, coding accuracy, population health characteristics, and financial outcomes, and translates findings into actionable recommendations that support organizational objectives.
Monitors and reports on key performance indicators, including risk score performance, encounter completeness, diagnosis prevalence and coding trends, documentation quality, data quality measures, financial impact, and forecasting performance.
Synthesizes complex data into clear, actionable insights and communicates business implications, opportunities, and risks to leadership and P&L stakeholders.
Evaluates drivers of risk score model performance across Medicaid populations and identifies opportunities to improve predictive accuracy, encounter quality, coding accuracy, and overall program effectiveness.
Reviews performance against peer organizations, market benchmarks, and organizational targets and recommends strategies and interventions to improve outcomes and maintain competitive positioning.
Partners with business, clinical, operational, financial, analytics, compliance, provider, vendor, and state-facing stakeholders to investigate performance drivers, validate findings, and support implementation of improvement initiatives.
Influences decision-making by connecting analytical findings to measurable business and financial outcomes and monitoring results over time.
Leads a team utilizing a matrix management system.