Your Role
The Commercial CMO Team provides clinical oversight for programs and processes that support members’ health care, reduce costs, and improve quality. The Program Manager Clinical, Consultant (Line of Business) reports to the Director of Program Management, Clinical – CMO. In this role, you will analyze clinical and financial data to identify trends and opportunities to improve care and manage costs for employer-funded health insurance, lead projects to address these opportunities and develop presentations that clearly communicate the clinical insights and recommended actions. You will also facilitate meetings with internal and external stakeholders and drive improvements in healthcare cost trends through both direct interventions and broader, system-level initiatives.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Work
In this role, you will:
Provide analysis, leadership, and guidance, for a given line of business, including opportunity identification, business case creation, and implementation
Provide steady leadership in the face of uncertainty, change, and aggressive deadlines common to a rapidly growing company with an evolving business model
Create presentations and manage meeting requests at a high level.
Lead cross-functional meetings and foster teamwork; drive escalation and resolution of issues, while promoting collaboration and coordination across broad categories of stakeholders
Collaborate with analytics, actuarial, and quality teams to develop, analyze, and distribute reports, and document program activities, interventions, and outcomes
Perform deep-dive analysis of high-cost claims, vendor-identified populations, and other defined groups, producing case studies, reports and presentations
Research and recommend interventions; identify and drive improvements and actions to significantly impact the cost of healthcare.
Conduct detailed reviews of high-cost claims and episodes of care to identify actionable cost-saving opportunities, including site-of-care optimization, inappropriate utilization, claims payment integrity issues, contractual compliance, and coordination of benefits
Analyze inpatient admissions, readmissions, specialty drug utilization, and high-cost professional and facility claims to identify key drivers of healthcare trend and develop targeted mitigation strategies
Identify opportunities for site-of-service steerage, provider network optimization and out-of-network utilization management, care management interventions, and benefit design enhancements to reduce total cost of care
Monitor emerging healthcare cost drivers, including specialty pharmaceuticals, oncology, behavioral health, specialist and emergency department utilization, and recommend appropriate interventions
Measure and communicate intervention outcomes, including savings realized, quality impacts, operational effectiveness, and member experience considerations
Partner closely with analytics teams to develop, analyze and distribute reporting
Liaise with analytics and cost of healthcare groups across the enterprise to compare trends, share knowledge, and measure outcomes
Organize and lead cross-functional meetings, foster teamwork and collaborative problem-solving across diverse stakeholders
Facilitate cross-functional taskforces with specific cost of healthcare commitments
Other duties as assigned
Your Knowledge and Experience
Requires a Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree and a completion of an accredited educational program that meets the requirements for applicable professional license
Requires at least 7 years of prior relevant…