Program Manager, Healthcare Services (Clinical Policy and Medicare Compliance)

About the Role

Provides subject matter expertise and leadership to the healthcare services function, supporting project, program, and process design, execution, evaluation, and compliance with regulatory and internal standards, practices, policies, and contractual commitments. Contributes to overarching strategy to deliver quality and cost-effective member care.

Responsibilities

• Collaboratively plans and executes internal healthcare services projects and programs involving department or cross-functional teams of subject matter experts, delivering products from design to completion.
• Provides ongoing communication related to program goals, evaluation, and support to ensure compliance with standardized protocols and processes.
• May engage and oversee the work of external vendors.
• Focuses on process improvement, organizational change management, program management, and other processes relative to business needs.
• Serves as a subject matter expert and leads healthcare services programs to meet critical needs.
• Communicates and collaborates with customers to analyze and transform needs and goals into functional requirements.
• Conducts quality audits to assess healthcare services staff educational needs and service quality, and implements quality initiatives within the department as appropriate.
• Creates business requirements documents (BRDs), test plans, requirements traceability matrix (RTMs), user training materials, and other related business documents.

Requirements

• At least 5 years of healthcare experience, including experience in clinical operations, and at least 3 or more years in one or more of the following areas: utilization management, care management, care transitions, behavioral health, or equivalent combination of relevant education and experience.
• Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Advanced Practice Social Worker (APSW), Certified Health Education Specialist (CHES), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC), or Licensed Marriage and Family Therapist (LMFT).
• Clinical licensure and/or certification required only if mandated by state contract, regulation, business operating model, or state board licensing. If licensed, the license must be active and unrestricted in the state of practice.
• Strong analytical and problem-solving skills.
• Strong organizational and time-management skills.
• Ability to work in a cross-functional, professional environment.
• Experience working within applicable state, federal, and third-party regulations.
• Strong verbal and written communication skills.
• Proficiency in Microsoft Office suite/applicable software programs, and ability to navigate online portals and databases.

Preferred Qualifications

• Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other healthcare or management certification.
• Leadership experience.
• Medicaid/Medicare population experience.
• Focus on clinical policy and Medicare compliance.

Pay

$65,791.66 - $142,548.59 per year.