Sr. Program Manager

Job Description

What You'll Do

• Review reports and records of activities to ensure progress is being accomplished toward specified program objective and modify or change methodology as required to redirect activities and attain objectives.
• Support clinical quality leadership on planning activities and large operational activities; works with Clinical Quality leaders to define success metrics and criteria.
• Develop, implement, and manage, moderately complex programs in accordance with guidelines. Work with program/project team and internal/external stakeholders to ensure deadlines are met.
• Manage and coordinate activities concerned with implementation and carrying out objectives of programs.
• Responsible for keeping current with HEDIS specifications and ensuring that all contractors and overreaders are knowledgeable about the latest updates.
• Identify, analyze, and understand target audiences and their specific program needs. 
• Performs quality audits of member medical records to ensure compliance with HEDIS specifications.
• Assists in designing effective learning solutions based on analysis of quality audit results and when quality deficiencies are identified.
• Monitors and reports on individual and department results to include benchmarking and trending.
• Works with management team to support decisions on workflow process, quality improvement, goal setting and data driven information-based decision-making.
• Provides timely feedback to management on HEDIS performance.
• Manage end to end HEDIS record review process. This includes oversight of reviewers, managing chase list process, manage reporting, tracking IRR’s, etc.
• May also support ongoing administration of larger and/or more complex programs.
• Establish and monitor performance metrics and goals for assigned programs, including process measures, outcomes measures, financial measures, and methodologies for implementing programs. Document and present program results through operational reports, outcomes studies, presentations, and publications.
• Serve as a subject matter expert in routinely briefing key stakeholders on different aspects of assigned initiatives.
• Manage vendor relationships and/or work closely with vendors.
• Other HEDIS duties or ad hoc requests, as assigned.

Knowledge and Experience

Strong analytical, organization, and problem-solving skills.

Strong written, and verbal communication skills and ability to successfully interact with all levels of management. Knowledge of clinical quality improvement operations, including HEDIS, Medical quality ratings, strongly preferred. Knowledge of Blue Cross NC or prior healthcare payer experience strongly preferred. HEDIS clinical measures data extraction is desirable. Experience in conducting patient chart reviews to obtain clinical measures is preferred.

Hiring Requirements

• Bachelor's degree or advanced degree (where required)
• 5+ years of experience in related field
• In lieu of degree, 7+ years of experience in related field

Hiring Preferences

• Nursing background
• Work experience in applicable business area (HEDIS, Medical Record Review, quality programs)
• Healthcare payer experience

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets,  licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. 

*Based on annual corporate goal achievement and individual performance.