Resp & Qualifications
The Program Manager is a new function that will support the Clinical Programs team in managing a portfolio of programs specific to Medicare Advantage as well as the expansion of existing commercial programs to our Medicare Advantage population. The Program Manager is responsible for the design, implementation, operations, communication and evaluation of a range of programs that serve our Medicare Advantage markets. Collaborates with Government Programs and other Program Managers on the team to liaison with our external vendor partners and manage the contractual relationship and day-to-day activities related to the Medicare Advantage market. Leads the design and build of an analytic infrastructure to manage vendor partner performance, evaluate the impact of the programs, and communicates a compelling value story. Ensures alignment with the overall corporate vision and goals by focusing on compliance, procedures and monitoring/control to achieve program goals.
ESSENTIAL DUTIES AND RESPONSIBILITIES include, but are not limited to, the following:
Percentage Duties and Responsibilities
Responsible for the design, implementation, and operations of a portfolio of clinical programs, ensuring smooth operations between CareFirst and the vendor partners. Serves as primary operational liaison with vendor partners; manages the contractual relationship including pricing, performance, contract terms, service level agreements and other key elements.
• Oversees the process of contracting, rate negotiations with vendor partners.
• Oversees all go-live activities to ensure that all parties are supported and assisted.
o Ensures efficient and high-quality installation of new programs and services and monitors all aspects of implementing projects.
o Lead for tracking, analyzing and ensuring resolution of system and/or process-based issues in the initial go-live phase.
• Trouble shoots barriers that limit program impacts, including day-to-day and systemic issues. Ensures that vendor partners provide services in accordance with services level agreements.
o Addresses escalated service issues, including onsite face to face meetings with executives to ensure the vendor partners resolve ongoing issues in acceptable long-term solutions.
o Conducts regular meetings with vendor partners to manage issue escalation, new program development and enhancements.
• Monitors claims payment activities and works with the appropriate business leaders across the organization to ensure resolution of escalated claims issues.
o Works with external providers and internal business units to ensure Program claims are accurately submitted and processed. Tracks and reports on the financial aspects of the Program.
• Oversees and evaluates clinical programs policies and procedures to ensure compliance with all CMS and state regulations and external accreditation standards pertaining to or affecting health care systems.
Lead the design and implementation of an analytic infrastructure to manage vendor partner performance, evaluate the impact of clinical programs, and communicates a compelling value story.
• Leads the design and implementation of reporting on the program’s operational and engagement metrics, clinical outcomes and cost of care, in collaboration with the Health Economics team.
• Evaluates and interprets complex program data to identify gaps in performance and identify opportunities for program optimization.
• Ensures that reporting supports management of vendor partner performance, including adherence to program guidelines, service level agreement, performance guarantees and/or other contractual obligations.
• Leads the preparation of quarterly performance summaries.
Performs the high-level tasks associated with general Program Management. Collaborates with internal stakeholders from Government Programs, Corporate Development, and the Division’s internal Care Management and Health Economics teams for the purpose of managing a portfolio of clinical programs.
• Oversees the interdependencies between various complex work streams and works to ensure the Program meets its goals and objective. Evaluates complex situations accurately and identifies viable solutions that create successful outcomes for the Program.
• Manages all aspects of Program, which may include conducting cost benefit analysis, developing work plans, monitoring of vendor service level agreements, designing policies and procedures, developing workflows, and implementing business and system monitors and controls.
• Provides both verbal and written communications regarding Program status, risks, issues, and risk mitigation plans. Makes recommendations on program decisions to leadership.
• Develops and maintains “lessons-learned” inputs for utilization on future projects.
• Coordinates the resolution of resource, budgeting, change, and legal issues affecting the Program.
• Bachelor’s degree in a healthcare management or business-related field; in lieu of Bachelor’s degree must have 4 years related work experience.
• 5-7 years of project or program management and/or consulting experience in healthcare or related environment, with a least 3 years work experience with Medicare Advantage.
• Subject matter expertise on Medicare Advantage rules and regulations as they apply to health plans, providers and/or care management programs.
• Ability to act as project lead on dynamic, multidisciplinary high-performance work teams to find creative solutions that optimize program goals and performance.
• Expert ability to synthesize complex data and analysis into clear, concise communications. Experience in developing executive level presentations and reports on strategic initiatives.
• Strong interpersonal skills, with the ability to communicate and influence others.
• Excellent oral and written communications; an ability to present and discuss analytical and technical information in a way that establishes rapport, persuades others, and gains understanding.
• Strong management, business planning, and organizational skills.
• Demonstrated proficiency with multiple reporting applications and tools, including MS Excel, Access, Word, PPT and Project.
• Knowledge of vendor management, including development of RFPs and SOWs and the tracking and monitoring of service level agreements.
• Knowledge of the health insurance industry and current and emerging health and wellness trends.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. 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.
• Master’s degree in Healthcare, Business or Technology related field.
• Project Management certificate (PMP) from the Project Management Institute (PMI).
• Thorough knowledge and understanding of the company’s business practices and direction, busi¬ness principles, and business processes, plus familiarity with the company’s products and resources.
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 6/21/2020
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.