Program Manager III - Quality - Delegated Provider Oversight

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 Delegated Provider Oversight Program Manager (Program Manager) manages programs and projects with significant complexity, risk and/or cost that support assigned programs and providers delegated for Utilization Management (UM) and/or Care Management (CM) activities. Key responsibilities include medium to large scale projects and initiatives. Responsibilities include successful implementation of large cross-functional projects to support the program(s), working closely with the appropriate Point32Health staff and external stakeholders to manage programs/projects, performing thorough and detailed policy and impact analysis, leading and/or representing the program in change initiatives that affect multiple departments. The Program Manager evaluates the cost and feasibility of multiple options/alternatives to resolve program issues and to make recommendations on those issues that best meet program and corporate Point32Health, as well as objectives. Change to ongoing programs at this level will usually require facilitating cross-departmental meetings as well as negotiations with outside parties/partners and contacts to explain and justify the impact. The Program Manager will also interact directly and regularly with leadership within the department and within Point32Health and others to accomplish successful program management. Key Responsibilities/Duties what you will be doing Overall program management of Care Management (CM) and Utilization Management (UM) Oversight Programs, focusing on both short-term initiatives and long-term strategic direction and objectives for the programs. The Program Manager is responsible for: o Leading day-to-day operations relating to providers delegated for Medicare and Medicaid applicable UM and/or CM activities. o Collaborating with individuals and groups across the enterprise and externally on new/existing documents, processes, activities, systems, and initiatives in response to program compliance requirements. Includes data collection and analysis of documentation from various sources to meet program requirements. o Providing operational oversight through regular communication, education and design of programs and strategies to assist delegated providers with meeting Point32Health expectations and CMS Medicare and State Medicaid compliance requirements. o 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. o Proactive and solutions-oriented management of program operations and integration issues, requiring the ability conceptualize and envision the impact of change, and propose new ways to do business to better meet the needs of the client/partner and Point32Health o Management of delegated providers preparation and delivery of documents and data to meet Point32Health requirements and CMS Medicare and State Medicaid compliance audits. o Collaborating with business partners to conduct qualitative and quantitative data analyses, formulate findings, draw conclusions, and make recommendations for action. o Preparing all written documentation associated with the program, including but not limited to project plans and detailed reports and ensures that all program requirements are met. o Management of cross-functional projects and initiatives o Applying program management skills to ensure transparency, reporting, and successful projects. Utilize project management expertise to ensure that workflows, processes, risks, communications, resources, and quality are managed appropriately internally and externally to support the program. The Program Manager will determine program needs and will direct project management as needed. The Program Manager will identify risks, concerns, or issues and escalate to management as appropriate. The individual will exercise judgment to make decisions and ensure programs/project is effectively progressing. Lead regular cross functional informational or working meetings, including effective agenda planning, facilitation, and tracking/follow up on deliverables until closed. Meetings include, but are not limited to, external stakeholders and internal business partners. Other duties and projects as assigned. Qualifications what you need to perform the job EDUCATION, CERTIFICATION AND LICENSURE: Bachelor s Degree required. Masters or Advanced degree in related industry and/or equivalent work experience in field related to Compliance or Regulatory responsibilities preferred. EXPERIENCE (minimum years required): 8-10 years business or industry experience. CMS Medicare and State Medicaid Agency/contract compliance requirements for Utilization Management, Care Management, Member Appeals and Grievances, in a State or Federal health plan setting preferred. 5-8 years of program management experience, including leading significant cross-functional, high-level initiatives. Leadership of programs and/or projects with a compliance/regulatory focus is preferred, preferably in a managed care or related health care environment. Accreditation experience preferred. Significant business process and program management experience related to the implementation of healthcare insurance business applications and products using industry-standard project and program management tools and techniques with established track record. A proven ability to meet deadlines is also required. SKILL REQUIREMENTS: Qualitative and quantitative data analysis experience. Highly developed oral and written communication skills, ability to communicate with and influence internal and external constituents at all levels with confidence. Using knowledge of company, able to resolve most roadblocks to program progress. Able to operate in a matrixed environment. May need to coordinate the participation of other internal contacts to develop and or maintain programs. Able to navigate political issues using advanced organizational (POINT32HEALTH) knowledge. Is an effective advocate for program and negotiates/leads others both internally and externally to participate in the program. May be required to coach/mentor less experienced program managers and effectively lead in a matrixed environment. Proactively identifies conflict/integration issues and leads team members to parse/synthesize issues of the highest complexity. Able to identify risk out of the larger picture and has a proven ability to accurately estimate and plan resource usage. Able to identify and make decisions that serve the best interests of POINT32HEALTH Detailed content knowledge of the specific program. Must be able to converse and lead dialogue on the subject with minimal direction; advanced training in the field related to the program is preferred. Ability to thrive in a matrix-management, hands-on environment that demands a consultative approach and solutions that span multiple environments in a business area. Outstanding communication and relationship management skills required, including the ability to effectively manage difficult group dynamics to effectively reach a positive outcome. Highest level presentation skills including ability to interface