Program Manager Clinical, Principal

2 days ago


Rancho Cordova CA, United States Blue Shield of California Full time

Your Role

The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The successful candidate will work with internal and external stakeholders understanding regulatory requirements, file preparation, letter and system accuracy, quality reporting, processes, and metrics.  This role will own the regulatory and accreditation audit work plan for function by understanding workflows, operational procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs). This position provides frontline support for nurses and coordinators and works in collaboration with leadership. The Clinical Compliance Principal works closely with subject matter experts for each line of business (LOB) to facilitate educational and change management processes as needed.

 

Your Work

In this role, you will: 

  • Develop new perspectives and innovative approaches on existing problems; require detailed information gathering, analysis and investigation to understand the problem. Problems are difficult and moderately complex, typically impact multiple departments or specialties, and are usually solved through drawing from prior experience and analysis of issues. 
  • Track and follow up on Corrective Action Plans (CAPs) and other information to be submitted to the Plan, to ensure evidence of corrective actions are in place.
  • Provide expert consultation and practice oversight of regulation adherence.
  • Design, develop and maintain an audit playbook and audit knowledge base repository; lead preparation and support for multiple regulatory audits annually, including audit universe and file prep.
  • Facilitate file and audit practice sessions with internal stakeholders.
  • Work with internal stakeholders to assure changing contractual and All Plan Letter (APL) requirements are incorporated into policies and procedures, as well as UM processes.
  • Department owner for UM Policy and Procedure updates to maintain alignment with APL and contractual requirements. 
  • Generally, responsible for managing major/complex projects involving delegation of work and review of work products; participates in workgroups/special projects for department as assigned.
  • Responsible for making moderate to significant improvements of processes, systems and products to enhance performance of job area.
  • Works to influence parties within and outside of the job function at an operational level regarding policies, procedures and practices. 

Your Knowledge and Experience

  • Current CA RN License. 
  • Bachelors of Science in Nursing or advanced degree preferred. 
  • At least 10 years of prior relevant experience in health plan. 
  • Utilization Management experience highly preferred
  • Experience with and strong working knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) and managed care for various lines of business (HMO, PPO, Medicare, Medi-Cal, Cal Medi-Connect)
  • Excellent analytical and problem-solving skills
  • Strong project management skills with multi-initiative leadership experience
  • Strong verbal/written communication and organizational skills 
  • Ability to work independently in a fast-paced and fluid work environment
  • Consistent demonstration of knowledge, skills, abilities, and behaviors needed to provide superior and culturally sensitive service to team members

Pay Range:

The pay range for this role is: $ 136400.00 to $ 204600.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

 

#LI-RU1



  • Rancho Cordova, CA, United States Blue Shield of California Full time

    Your Role The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits. Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Rancho Cordova, CA, United States Blue Shield of California Full time

    Your Role The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Rancho Cordova, United States Blue Shield of California Full time

    Your Role The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Rancho Cordova, United States Blue Shield of California Full time

    Your Role The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Rancho Cordova, United States Blue Shield of California Full time

    Your Role The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Rancho Cordova, United States Blue Shield of California Full time

    Your Role The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Rancho Cordova, United States Blue Shield of California Full time

    Your Role The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Rancho Cordova, United States Blue Shield of California Full time

    Your RoleThe Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Rancho Cordova, United States Blue Shield of California Full time

    Your Role The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team’s audit playbook for all lines of business for all regulatory and mock audits.  Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The...


  • Long Beach, CA, United States Blue Shield of California Full time

    Your Role The Blue Shield Behavioral Health Clinical Strategy and Programs team works with internal and external business and clinical partners to develop, execute, and evaluate Blue Shield of CA’s strategy for behavioral health and addiction medicine, which we refer to as “Behavioral Health, Re-Imagined.” This Program Manager Clinical, Principal...


  • Long Beach, CA, United States Blue Shield of California Full time

    Your Role The Blue Shield Behavioral Health Clinical Strategy and Programs team works with internal and external business and clinical partners to develop, execute, and evaluate Blue Shield of CA’s strategy for behavioral health and addiction medicine, which we refer to as “Behavioral Health, Re-Imagined.” This Program Manager Clinical, Principal role...


  • Long Beach, CA, United States Blue Shield of California Full time

    Your Role The Care Management department, which oversees all care management for the Dual Special Needs Program (DSNP) line of business, is seeking a Clinical Program Manager, Principal to join our team.   In this role, the candidate will provide comprehensive support and collaborate effectively with stakeholders across various departments. The ideal...


  • Long Beach, CA, United States Blue Shield of California Full time

    Your Role The Care Management department, which oversees all care management for the Dual Special Needs Program (DSNP) line of business, is seeking a Clinical Program Manager, Principal to join our team. In this role, the candidate will provide comprehensive support and collaborate effectively with stakeholders across various departments. The ideal...


  • Long Beach, CA, United States Blue Shield of California Full time

    Your Role The Care Management department, which oversees all care management for the Dual Special Needs Program (DSNP) line of business, is seeking a Clinical Program Manager, Principal to join our team.   In this role, the candidate will provide comprehensive support and collaborate effectively with stakeholders across various departments. The ideal...


  • United States, CA, Long Beach, 90802 Blue Shield of California Full time

    Your Role The Blue Shield Behavioral Health Clinical Strategy and Programs team works with internal and external business and clinical partners to develop, execute, and evaluate Blue Shield of CA’s strategy for behavioral health and addiction medicine, which we refer to as “Behavioral Health, Re-Imagined.” This Program Manager Clinical, Principal role...

  • Relationship Manager

    2 weeks ago


    Cordova, Tennessee, United States Principal Financial Group Full time

    About the RoleWe are seeking a skilled Relationship Manager to join our team at Principal Financial Group. As a key member of our Customer Care area, you will develop deep relationships with advisors, plan sponsors, and third-party administrators in our 25M - 200M market space in the Memphis, TN area.Key ResponsibilitiesCollaborate with plan sponsors and...

  • Relationship Manager

    2 weeks ago


    Cordova, Tennessee, United States Principal Financial Group Full time

    About the RoleWe are seeking a skilled Relationship Manager to join our team at Principal Financial Group. As a key member of our Customer Care area, you will develop deep relationships with advisors, plan sponsors, and third-party administrators in our 25M - 200M market space in the Memphis, TN area.Key ResponsibilitiesCollaborate with plan sponsors and...

  • Relationship Manager

    3 weeks ago


    Cordova, Tennessee, United States Principal Financial Group Full time

    About the RoleWe are seeking a skilled Relationship Manager to join our team at Principal Financial Group. As a key member of our Customer Care area, you will develop deep relationships with advisors, plan sponsors, and third-party administrators in our 25M - 200M market space in the Memphis, TN area.This role is the strategic partner to our clients and...


  • Rancho Cordova, California, United States Brown and Caldwell Full time

    Job Title: Principal Structural EngineerBrown and Caldwell, a leading environmental engineering firm, is seeking a highly skilled Principal Structural Engineer to lead our structural design team. As a key member of our team, you will be responsible for providing technical expertise and project leadership to deliver high-quality designs for our clients.Key...


  • Rancho Cordova, United States Blue Shield of California Full time

    Your Role The Clinical Quality Analytics and Informatics team delivers best-in-class clinical quality analytics and informatics to enable high quality and affordable member-centered care. Our data, intelligence, and actionable insights help drive quality strategy, performance improvement, and regulatory reporting. The Clinical Quality Analyst - Senior...