Program Manager, Principal - Medicare PPO

Blue Shield of California•Oakland, CA

8d•Hybrid

About The Position

Your Role The Program Manager, Principal provides leadership and operational support to advance quality performance across clinical programs and contracted provider groups. This role drives the implementation, oversight, and continuous improvement of quality structures, processes, and outcomes necessary to achieve high performance in Medicare Stars, HEDIS, risk adjustment, preventive care, and value‑based care programs for a PPO product line. This position partners closely with internal teams, including Clinical Quality, Medicare Stars, Product, IT, Finance, Population Health, Clinical Integration, and Medicare Operations—as well as external provider groups to ensure successful execution of quality initiatives and organizational goals. 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

Bachelor’s Degree or equivalent combination of education and experience.
10 years of increasingly responsible experience in healthcare quality, population health, or clinical operations.
Demonstrated experience in project/program management.
Experience with quality performance measures such as HEDIS, Medicare Stars, patient experience measures, and risk adjustment models in the PPO space or Fee for Service (FFS) space.
Ability to interpret and use quantitative and quantitative data to drive improvement.
Knowledge of quality improvement practices and methodologies.
Lean, Six Sigma, or Performance Improvement training or certification.
Intermediate to advanced proficiency with Microsoft Excel, PowerPoint, and other analytical/project management tools.

Responsibilities

Provide overall program leadership, guidance, and management of mid‑size and complex quality improvement projects, including requirements gathering, business case creation, planning, execution, and implementation.
Maintain all project management components including timelines, scope, risks/issues, resources, and stakeholder communication.
Lead cross‑functional meetings, drive issue escalation and resolution, and foster collaboration across diverse stakeholder groups.
Support and coach team members and internal project managers on project execution and improvement methodologies.
Partner with organizational leadership to advance Population Health initiatives and multi‑specialty quality and value‑based care programs related to clinical quality, risk adjustment, care optimization, cost-of-care initiatives, and performance measurement within the PPO product line.
Collaborate with operational leaders to execute against quality, care, and financial measures.
Track performance across various program models (e.g., HEDIS, Medicare Stars) and coordinate stakeholders to identify gaps, barriers, and improvement opportunities.
Oversee the production, interpretation, and dissemination of dashboards, analytics, and insights that drive performance improvement across provider groups and clinical programs.
Analyze quality and quantitative data to identify trends, variation, and opportunities for improvement; guide stakeholders in developing effective action plans.
Maintain and report quality performance for Medicare PPO product.
Work with leadership to identify improvement priorities, establish annual goals, and facilitate performance improvement work utilizing Lean, Six Sigma, or other improvement methodologies.
Coach leaders and clinic teams in the application of quality improvement tools, methods, and best practices.
Coordinate the ongoing review, update, and communication of quality‑related policies, procedures, and workflows to support high performance and outstanding clinical outcomes.
Maintain current knowledge of national and local public reporting initiatives, regulatory updates, and clinical quality standards that impact organizational performance.
Manage complex relational dynamics within provider groups and external partners while educating Stars/HEDIS requirements and other quality‑related program expectations.
Identify innovation opportunities and support adoption of quality improvement actions with external provider partners.
Serve as subject matter expert and liaison for CMS and payer communications related to quality programs.
Perform other duties as assigned.