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 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.