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Clinical Program Manager Consultant

2 months ago

Shingle Springs, California, United States Blue Shield of CA Full time
Job Title: Clinical Program Manager Consultant

We are seeking a highly skilled Clinical Program Manager Consultant to join our team at Blue Shield of California. As a key member of our organization, you will play a critical role in delivering high-quality care management services to our members.

About the Role

This is a leadership position that requires a strong clinical background, excellent analytical and problem-solving skills, and the ability to work independently with minimal oversight.

Key Responsibilities:
  • Subject Matter Expertise: Support the overall FEP CM team as a subject matter expert, exemplifying Blue Shield leadership behaviors.
  • Electronic Medical Record (EMR) Systems: Contribute to the adoption, evaluation, and ongoing improvement of EMR systems.
  • Go-Live Testing: Participate in go-live testing, which may occur after hours or on weekends, based on the posted monthly release schedule.
  • Operational Targets: Work to achieve operational targets defined by the Blue Cross Blue Shield Association (BCBSA) by preparing and assisting with review and submission of Care Management data.
  • HEDIS Measures: Create and educate the team on specifications around the Healthcare Effectiveness Data and Information Set (HEDIS) measures selected by Office of Personnel Management (OPM).
  • Caseload Management: Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards.
  • Team Leadership: Lead team huddles/meetings to support process changes and encourage collaboration of team members.
  • Departmental Goals: Contribute to the development of goals for the department and planning efforts (budgets, operational plans, etc.).
  • Business Unit Performance: Influence the performance of the business unit in achieving Blue Shield of California's objectives.
  • Contractual Reporting: Responsible for collecting data required for contractual reporting.
  • Employee Development: Responsible for auditing, providing guidance, coaching, training, and precepting to other employees within job area.
  • Training and Development: Collaborate with the training department and operation department to customize training specific to the FEP team.
  • Internal and External Audits: Prep cases for internal and external audits.
  • Referrals: Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD).
Requirements:
  • Education and Experience: Typically requires a college degree or equivalent experience and minimum 7 years of prior relevant experience.
  • Clinical Licensing or Certification: Clinical licensing or certification requirements may apply depending upon position. RN, OT, MSW, CPHQ Cert preferred.
  • Certification: Certified Case Manager (CCM) Certification or qualifies to complete certification when eligible based on CCM application requirements preferred.
  • EMR Systems: Demonstrated ability to test EMR systems and guide the development of acceptance criteria statements to improve the EMR systems.
  • Clinical Practice Guidelines: Extensive knowledge of evidenced-based clinical practice guidelines particularly for chronic conditions.
  • Regulatory and Accreditation Standards: Working knowledge of regulatory and accreditation standards preferred (NCQA, Case Management Society of America CMSA).
  • CM Functions and Standards: Demonstrated and evolving competence in CM functions and standards of practice.
  • Coordination of Care: Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care, and length of stay criteria sets desirable.
  • Clinical Assessment and Evaluation: Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
  • Analytical and Problem-Solving Skills: Excellent analytical and problem-solving skills.
  • Clinical Documentation: Strong clinical documentation skills, independent problem identification, and resolution skills.
  • Microsoft Applications: Proficiency with Microsoft applications including Word, Excel, Outlook, and Teams.
  • Cultural Awareness: Possesses cultural awareness to work effectively, respectfully, and sensitively within the client's cultural context.
  • Community Resources: In-depth understanding of community resources, treatment options, home health, funding sources, and special programs.
  • Independence: Ability to work independently with limited oversight.
Pay Range:

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

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.