Additional Locations:

　　Full Time Remote - Alabama, Full Time Remote - Alabama, Full Time Remote - Arizona, Full Time Remote - Arkansas, Full Time Remote - Colorado, Full Time Remote - Florida, Full Time Remote - Georgia, Full Time Remote - Idaho, Full Time Remote - Indiana, Full Time Remote - Iowa, Full Time Remote - Kansas, Full Time Remote - Kentucky, Full Time Remote - Louisiana, Full Time Remote - Maryland, Full Time Remote - Michigan, Full Time Remote - Mississippi, Full Time Remote - Missouri, Full Time Remote - Ohio, Full Time Remote - Oklahoma, Full Time Remote - Pennsylvania, Full Time Remote - South Carolina, Full Time Remote - South Dakota, Full Time Remote - Tennessee, Full Time Remote - Texas, Full Time Remote - Utah {+ 2 more}

　　Job Description

　　As a Senior Program Manager, you will collaborate and engage with multiple internal stakeholders and external customers (i.e., providers, vendors, employer groups) to implement D-SNP population health management and promote a collaborative, integrated culture across lines of business/segments. In this role, you will support value-based strategy by leading multiple clinical or non-clinical teams/staff focused on improving member health through proactive and professional services in the following areas: clinical determinations, case management, disease management, wellness, medical policy, medical review, and/or related services. This position coordinates with clinical experts and system resources as appropriate.

　　What You’ll Do

　　Overall responsibility for compliance and outcomes associated with Model of Care requirements

　　Oversight of annual MOC training process with provider community

　　Overall responsibility for STARs strategy execution, medical expense initiative results, accurate risk coding, network, SDOH, and pharmacy

　　Focus on strategic alignment of clinical initiatives and identifying opportunities to enhance capabilities to manage clinically and socially complex dual eligible population

　　Consult on Model of Care program designs, redesign, and implementation for efficiency and effectiveness

　　Assist in the development of D-SNP Model of Care strategies and innovative solutions for area(s) of clinical oversight; facilitate favorable medical expense, administrative pricing and/or efficiencies.

　　Focus on strategies to enhance provider engagement and align incentives to support STARs, accurate risk coding, member engagement and financial outcomes

　　Maintain awareness of trends, developments, and governmental regulations in Model of Care requirements.

　　Manage the operational performance of D-SNP clinical functions including Clinical Determinations, Case Management, Disease Management, Wellness, Medical Policy, Medical Review and/or related services for different line(s) of business to ensure performance standards are met and in compliance with employer groups, FEP Directors’ Office, and/or applicable state and federal regulations.

　　Initiate and manage service initiatives/programs to facilitate and promote quality, cost effective outcomes and minimize the impact of fragmented health care delivery on the customers.

　　Facilitate and incorporate complex clinical and financial decision making in the day-to-day operations by presenting thoroughly analyzed cases requiring high administrative approval or intervention.

　　Establish and monitor performance and production metrics and goals, including process measures, outcomes measures and financial measures.

　　Manage, and/or support implementation of departmental, divisional, or corporate projects that impact the clinical aspects of the service(s) under leadership purview.

　　Assist with the evaluation and management of vendor and partnership opportunities.

　　Collaborate with the leadership accountable for applicable vendors supporting business area needs.

　　Oversee or participate in internal committees relevant to work responsibilities; may represent the department through presentations and/or active participation in cross functional organizational committees

　　Implement an integrated continuous quality improvement and change process to assure high quality care, innovation, customer satisfaction and contribution to financial performance of the Program or Operations.

　　Serve as primary contact for Model of Care compliance and regulatory audits.

　　Ensure programs and operational changes are communicated to all appropriate internal and external stakeholders in accordance with policies and regulations.

　　What You’ll Bring

　　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.

　　What We Like

　　Clinical operations experience, preferred

　　2+ years Medicare/DSNP experience in health care organization/system, or care management

　　Experience in population health, care management, clinical review or coding, or utilization management in a health care organization/system or health insurance

　　If you’re ready to make a career out of making a difference, this is the opportunity for you.

　　We invite you to check out our careers site to see we value diversity and inclusion at all levels of our organization. We have inclusion challenges throughout the year and affinity groups that are an integral part of our culture!

　　It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.

　　Blue Cross NC is a fully taxed, not-for-profit North Carolina company with major operations centers in Durham and Winston-Salem. We employ more than 5,000 people who are passionate about health care, and we serve more than 4.3 million members.

　　Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

　　E-Verify

　　Our company uses E-Verify to confirm the employment eligibility of all newly hired employees. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.

　　Third Party Staffing Agencies

　　Blue Cross NC does not accept unsolicited resumes from any source other than directly from candidates. For the protection of all parties involved in the recruiting process, resumes will only be accepted from recruiters/agencies if a signed agreement is in place at the inception of the recruiting effort and authorized for a specific position. Unsolicited resumes sent to Blue Cross NC from recruiters/agencies do not constitute any type of relationship between the recruiter/agency and Blue Cross NC and do not obligate Blue Cross NC to pay fees if we hire from those resumes.