at Point32Health in Chicago, Illinois, United States
Job Description
Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.
Job Summary
The Clinical Program Manager is a Registered Nurse who performs program oversight activities to optimize the quality of Program services; this involves ensuring compliance and validating interpretation with regulatory/ contractual/ accreditation/ compliance requirements. This role provides clinical support to the Program as well as develops effective working relationships across partnering business areas and external entities.
The Clinical Program Manager is a highly motivated individual with an understanding of processes within lines of business (e.g., Care Management (CM), Medical Policy, etc.). Focus is particularly in the managed care environment with a focus on identified populations (i.e., Medicare, Medicaid).
Through organizational awareness and knowledge of industry best practices and innovation, this position provides recommendations to improve outcomes of assigned services such as CM and UM (Utilization Management). The Clinical Program Manager works directly and regularly with Point32Health leadership at all levels on high profile initiatives that support programmatic and organizational success. This position serves as a key resource for internal and external customers.
Key Responsibilities/Duties – what you will be doing
- Establishes and maintains productive and positive working relationships with all levels of the organization; cultivates clear lines of communication by interacting regularly with internal and external stakeholders.
- Ensures compliance of internal and / or external CM and UM, as applicable, with regulatory, contractual, accreditation and business requirements through in-depth evaluations involving qualitative and quantitative data analysis, scientific evidence review, and review of complex issues. Reports findings to internal constituents and collaborates with colleagues to optimize performance. Adapts presentations to support effective engagement across audiences.
- Performs overall management of the Program, focusing on both short-term initiatives and long-term strategic direction and objectives. Monitors all relevant internal and / or external documents, processes, and systems against contractual, accreditation and business requirements.
- Completes collaborative work at the required frequency (e.g., quarterly, semi-annual, annual) focused, and periodic audit/review activities timely and thoroughly.
- Develops and conducts ongoing monitoring activities. Creates mechanisms to track and trend progress of Program compliance to provide ongoing performance feedback and identify system wide issues.
- May develop and administer programs/processes changes, and oversight management of ongoing program and processes.
- Acts as a clinical resource for best practices and assesses trends in the data to identify drivers and provide recommendations on opportunities for improvement to enhance outcomes.
- Acts as a clinical resource to the department as assigned.
- Other duties and projects as assigned.
Qualifications – what you need to perform the job
Education, Certification and Licensure
- Bachelor’s degree in nursing or related field required
- Registered Nurse with current unrestricted license required
- Master’s degree in healthcare related field preferred
- Certified Professional in Healthcare Quality (CPHQ) and / or Certified Case Manager (CCM) preferred
Experience (minimum years required):
- 5 or more years’ experience in a clinical setting required
- Experience in care management in a provider setting and/or managed care setting is highly desirable
- Leadership of programs / projects with an accreditation/compliance/regulatory focus is preferred, preferably in a managed care or related health care environment
- Experience with CMS Medicare and State Medicaid agency/contract compliance and accreditation requirements for Care Management, Utilization Management, and / or Member Appeals and Grievances in a health plan setting preferred
