Program Manager Clinical, Consultant -Cost of Healthcare Analysis

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.

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.

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.