Program Manager, Clinical Compliance

The Role:

The Clinical Compliance Program Manager will focus on utilization management compliance and audit readiness activities such as evaluating and supporting Health and Medical Management's (HMM) and delegate's compliance with the applicable NCQA utilization management standards and state and federal regulations.

This position leverages analytical, leadership and organizational skills to perform audits, summarize and communicate findings to various levels in the organization, perform gap analysis, risk assessment, track issues/ risks to closure, and collaboratively develop mitigation strategies. Other NCQA accreditation work includes delegation oversight and preparing documentation for accreditation submission.

The Team:

As an integral part of HMM Quality and Compliance team, the Clinical Compliance Program Manager works through the influence as an individual contributor while collaborating and providing guidance to HMM teams, company leaders within and outside of HMM, and to external delegates to achieve compliant processes.

Key Responsibilities:

• Evaluate NCQA, Rhode Island, & Massachusetts utilization management related compliance including:

• Lead internal audits that identify risks and areas for improvement in processes, policies, and systems
• Communicate audit findings, risk insights, and recommendations effectively to diverse audiences, from operational teams to executive leadership
• Apply their clinical knowledge when assessing/auditing medical records and UM letters against medical necessity criteria and accreditation and regulatory criteria
• Implement new NCQA standards or regulatory requirements
• Ensure policies and procedures are up to date and reflect the appropriate compliance with regulatory and accreditation requirements
• Perform delegation oversight activities

• Represents department on cross functional workgroups and projects as a subject matter expert (SME) and sharing expertise with teammates, HMM associates, and leaders
• Collaborate with leaders to identify/ implement workflows and process improvements to maximize quality, efficiency, and cost effectiveness
• Other responsibilities as assigned by the Director

Key Qualifications:

• Ability to work autonomously and drive initiatives to successful and timely completion through well-developed critical thinking, planning, organization, and time management skills
• Demonstrated leadership skills including building trusting and credible relationships & consensus building, negotiating, influencing, the ability to manage change
• Strong written communication, meeting facilitation, and presentation skills
• Ability to navigate Care Prominence UM system, interpret, & analyze data; Proficient in Word, Excel, Adobe Acrobat Pro, PowerPoint, AI, and Outlook
• Working knowledge of NCQA UM accreditation requirements, Massachusetts, and Rhode Island utilization review regulations
• Working knowledge of compliance and quality improvement techniques

Education and Experience:

• RN or clinical professional degree with active Massachusetts clinical license with 3-5 years of clinical experience
• Bachelor's degree required
• 3 years of Utilization Management experience at a health plan; Medical Surgical or Pharmaceutical utilization management or clinical experience preferred
• 1-2 years experience of managing people or projects
• 2-5 years of experience working with utilization management regulatory and accreditation standards, such as NCQA, Massachusetts utilization review regulations, Rhode Island utilization review regulations, Federal Employee Plan, or CMS including experience with auditing and monitoring corrective action plans.

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.