Your Role
The Commercial CMO Team provides clinical oversight for programs and processes that support members' health care, reduce costs, and improve quality. The Program Manager Clinical, Consultant (Line of Business) reports to the Director of Program Management, Clinical – CMO. In this role, you will analyze clinical and financial data to identify trends and opportunities to improve care and manage costs for employer-funded health insurance, lead projects to address these opportunities and develop presentations that clearly communicate the clinical insights and recommended actions. You will also facilitate meetings with internal and external stakeholders and drive improvements in healthcare cost trends through both direct interventions and broader, system-level initiatives.
Your Work
In this role, you will
- Provide analysis, leadership, and guidance, for a given line of business, including opportunity identification, business case creation, and implementation
- Provide steady leadership in the face of uncertainty, change, and aggressive deadlines common to a rapidly growing company with an evolving business model
- Create presentations and manage meeting requests at a high level.
- Lead cross-functional meetings and foster teamwork; drive escalation and resolution of issues, while promoting collaboration and coordination across broad categories of stakeholders
- Collaborate with analytics, actuarial, and quality teams to develop, analyze, and distribute reports, and document program activities, interventions, and outcomes
- Perform deep-dive analysis of high-cost claims, vendor-identified populations, and other defined groups, producing case studies, reports and presentations
- Research and recommend interventions; identify and drive improvements and actions to significantly impact the cost of healthcare.
- Conduct detailed reviews of high-cost claims and episodes of care to identify actionable cost-saving opportunities, including site-of-care optimization, inappropriate utilization, claims payment integrity issues, contractual compliance, and coordination of benefits
- Analyze inpatient admissions, readmissions, specialty drug utilization, and high-cost professional and facility claims to identify key drivers of healthcare trend and develop targeted mitigation strategies
- Identify opportunities for site-of-service steerage, provider network optimization and out-of-network utilization management, care management interventions, and benefit design enhancements to reduce total cost of care
- Monitor emerging healthcare cost drivers, including specialty pharmaceuticals, oncology, behavioral health, specialist and emergency department utilization, and recommend appropriate interventions
- Measure and communicate intervention outcomes, including savings realized, quality impacts, operational effectiveness, and member experience considerations
- Partner closely with analytics teams to develop, analyze and distribute reporting
- Liaise with analytics and cost of healthcare groups across the enterprise to compare trends, share knowledge, and measure outcomes
- Organize and lead cross-functional meetings, foster teamwork and collaborative problem-solving across diverse stakeholders
- Facilitate cross-functional taskforces with specific cost of healthcare commitments
- Other duties as assigned
Your Knowledge and Experience
- Requires a Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree and a completion of an accredited educational program that meets the requirements for applicable professional license
- Requires at least 7 years of prior relevant experience
- Requires current California LVN, RN, NP, or PA license
- Prefers familiarity with health care data and the health care delivery system in California; health plan or provider experience strongly desired
- Strong organizational and/or project management skills, consistent ability to "self-start" and take ownership of end-to-end taskforce activities
- Excellent written and oral communication skills, ability to facilitate cross-functional discussions, lead teams through influence to drive actions and outcomes
- Experience in cost of health care analysis, population health outcomes, and/or program evaluation desired
- Expertise in analyzing high-cost claims, episodes of care, and healthcare cost drivers to identify opportunities for medical cost reduction desired
- Ability to review complex claims for payment accuracy, contractual compliance, coordination of benefits, and potential payment integrity issues desired
- Prefers knowledge of provider reimbursement methodologies, including DRG, case rate, per diem, percentage-of-charge, and letter-of-agreement arrangements
- Experience identifying fraud, waste, abuse, upcoding, unbundling, inappropriate billing, and other claim-payment vulnerabilities desired
- Experience performing root-cause analyses of trend drivers and developing business cases for cost-of-care interventions desired
- Strong proficiency using data visualization and analytical tools such as Power BI and other reporting platforms to communicate findings and recommendations
- Experience working with employer fully insured and self-insured populations, large group accounts, and multidisciplinary stakeholder groups
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.