Sr. Manager, Enhanced Clinical Programs Surgery Medical Services

Blue Shield Of California Rancho Cordova , CA 95741

Posted 6 months ago

Job Description: for Senior Manager, Surgical/Medical Services, Healthcare Value Solutions & Enhanced Clinical Programs:

The Senior Manager, Surgical/Medical, Enhanced Clinical Programs reports directly to the Director of Healthcare Value Solutions and Enhanced Clinical Programs. This position interfaces, supports and collaborates with the Sr. Director of Healthcare Value and Affordability, Health Care Quality and Affordability Operations Directors and Executive Staff, Product and Benefits Directors, Data Analytics, Medical Policy, Networks and the Cost of Healthcare Governance team. The Senior Manager is responsible for managing the surgical and medical programs within the department portfolio, which includes programs in cardiology, maternity, women's health, orthopedics, bariatric and metabolic medicine and diabetes. In addition, the Senior Manager will be chartered with reviewing and analyzing clinical data, claims data, industry best practices, professional guidelines and industry program trends in order to develop business cases for new and existing programs that enhance member care, quality, and affordability of healthcare. The Senior Manager is accountable for the successful implementation and ongoing tracking of all program effectiveness and efficiency, provider abrasion and member access. The Senior Manager supports $50M in cost of healthcare targets for Healthcare Value Solutions and Enhanced Clinical Programs and is accountable for the identification and implementation of new programs to support ongoing COHC savings. This Sr Program Manager is specifically responsible for:

  • Researching industry sources such as, but not limited to, CMS, ICER, Hayes, JAMA, Blue Cross Blue Shield Association and Association plan members for emerging clinical and industry program trends; synthesizing that information into program opportunities, reviewing with clinical and operational leaders to formalize a clear program design

  • Partnering with data analytics teams to identify outlier data trends of healthcare services, unit cost and provider utilization trends, synthesizing that information into program opportunities, reviewing with clinical and operational leaders to formalize a clear program design

  • Building and leveraging industry professional network relationships, including Blues partners, academic and community clinical thought leaders for emerging clinical and industry program trends, synthesizing that information into program opportunities, reviewing with clinical and operational leaders to formalize a clear program design

  • Partnering with finance and actuarial teams, operational leaders and/or vendors to create a sound business case with business need, objectives, scope, program costs and program benefits and presenting to senior leaders for approval and/or funding

  • Development of an initiatives roadmap and tracking and monitoring of program performance against the business case to demonstrate value in enhanced member care quality and improved stewardship of member premiums

  • Development and refinement of the process by which enhanced clinical programs are brought from ideation to realization

  • Providing strong and collaborative leadership to your team and the overall department

  • Participation in BSC and BCBSA forums and committees

Required knowledge, skills and experience for this role include the following:

  • Deep payor knowledge (8 years) with a strong understanding of utilization management, medical policy, healthcare economics, contracting and benefits

  • Strong independent judgment, critical and analytical thinking, problem-solving and data-driven decision making skills

  • Ability to partner, collaborate with and influence relevant stakeholders, both internal and external. Strong oral and written communication, relationship and consensus-building skills

  • Strong clinical research skills

  • Strong professional networking skills

  • Demonstrated ability to drive to quality decisions with teams, peers and leaders.

  • Excellent Leadership/management skills, organization skills and facilitation skills

  • Experience with business case development and working with vendors

  • Experience with surgical and non-surgical procedures and techniques

  • Familiar with medical policy and appropriate use guidelines

  • Strong understanding of the business of health care

  • Intermediate project management skills

Education Requirements:

  • Bachelor's required, Masters preferred;
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Sr. Manager, Enhanced Clinical Programs Surgery Medical Services

Blue Shield Of California