Program Manager Clinical, Consultant -Cost of Healthcare Analysis

Our take on this role

About this role

Analyze clinical and financial data for employer-funded health insurance to identify care improvements and cost savings. Lead projects addressing these opportunities and present findings and recommended actions.

What could you bring from clinical work?

• Nurses: Your experience reviewing episodes of care for patterns in healthcare use could help with reviewing high-cost claims and recommending interventions.

Full job description from Blue Shield of California

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.

Responsibilities

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

Qualifications

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.

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.