Program Manager II - Quality -Auditing and Monitoring

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 Program Manager II is responsible for projects and initiatives with significant cross-functional interface that support assigned programs. Responsibilities include managing major departmental programs with significant cross functional interface with moderate complexity, risk and/or cost. Responsibility may include development of new programs as well as management of ongoing programs. Changes to programs require some negotiation and change management skills to implement. By using knowledge of the company, the Program Manager II should be able to resolve most roadblocks to ensure success and progress. The Program Manager II should make recommendations for change by performing cost/benefit analysis and by using basic analytical and problem-solving capabilities to support the recommendation. Will also directly interact with Point32Health leadership. Key Responsibilities/Duties what you will be doing Manage ongoing Care Management (CM) and Utilization Management (UM) Oversight Program operations. This may include: Monitoring all relevant UM and/or Member Appeals and Grievances internal plan documents, processes, and systems against CMS Medicare, State contract, and State Medicaid Agency compliance requirements. Developing and maintaining the appropriate auditing, monitoring, and tracking tools. Performing auditing and monitoring of internal UM and/or Member Appeals and Grievances files. Analyzing audit results and collaborating with partnering business areas to identify and prioritize opportunities for improvement and implement action plans that meet Medicare and Medicaid program and health plan objectives. Working with multiple areas within the organization to ensure effective, accurate, timely processes and workflows. Participating in and assisting as needed with preparation for all internal and external audits, site visits, meetings (on or off-site) as assigned. External organizations may include but are not limited to CMS, State Medicaid agencies, and External Quality Review Organizations. Perform detailed policy and impact analysis as it relates to oversight programs; make recommendations for process and/or policy change; present to various levels of the organization the findings and summary options. This includes determining data scope, consulting with Point32Health colleagues, performing analyses, and determining both quantitative and qualitative business implications. Collaborates with individuals and groups across the enterprise to develop new documents, processes, activities, systems, and initiatives in response to program compliance requirements, including data collection and analysis of documentation from various sources to meet program requirements. Lead and/or manage projects and/or initiatives by representing program operations during planning and implementation phases. This may include: Preparing written documentation associated with the program, including but not limited to project plans and detailed reports to ensure that all program requirements are met. Proactively identifying issues and facilitating effective issues resolution and/or escalation. Supporting other company programs and coordinating issue resolution with relevant functional business areas, and leading and/or facilitating planning and review sessions Lead reg lar cross functional informational or working meetings, including effective agenda planning, facilitation, and tracking/follow up on deliverables until closed. Other duties and projects as assigned. Qualifications what you need to perform the job EDUCATION, CERTIFICATION AND LICENSURE: Bachelor s Degree required. Advanced degree preferred EXPERIENCE (minimum years required): 3-5 years of health plan experience with 6-8 years working experience Program management or equivalent experience leading significant department level initiatives. Leadership of projects with a compliance/regulatory focus is required, preferably in a managed care or related health care environment. Experience with CMS Medicare and State Medicaid Agency/contract compliance requirements for Utilization Management, Member Appeals and Grievances, and/or Care Management, in a State or Federal health plan setting preferred. Accreditation experience preferred. SKILL REQUIREMENTS: Excellent verbal and written communication skills generally acquired through college or other advanced education is required. Ability to facilitate planning and review sessions. High level presentation skills including ability to interface effectively with external contacts. Ability to exercise sound judgment and raise issues to appropriate team members or management for resolution. Ability to conceptualize the impact of change and propose new methods of conducting business. Ability to use analytical skills to develop new or implement change to existing program functions. Ability to interpret and explain the implications of planned changes to current state business units. Ability to problem solve and overcome obstacles to ensure successful program operations. Technical skills: Proficiency with MS Office applications (Word, Excel, PowerPoint) Ability to utilize multiple applications simultaneously Interpersonal skills Requires the ability to work cooperatively as part of a team. Must be able to effectively communicate with all internal departments in verbal and written formats. Requires some presentation experience. Must be able to work in a matrix environment with minimal supervision. Security Clearance (if applicable): The position may require a background investigation and fingerprint form on file with the US Office of Personnel Management. Questionnaire For Public Trust Position (standard form 85P) must be completed and approved. Access to several secure government websites may be needed. WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel): Must be able to work under normal office conditions and work from home as required. Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. May be required to work additional hours beyond standard work schedule. DISCLAIMER The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.