SCOPE OF ROLE

The Clinical Program Manager will lead the program design, policy development, implementation and evaluation of Bright Health’s catastrophic/ high-cost cases.  Program initiatives may include identifying incurred costs and prediction of future costs of care and discussion with stop loss carriers and agents, Finance, and Actuarial teams, and coordination of care across the care spectrum. This position will provide leadership to cross functional work teams and provide programmatic subject matter expertise. The Clinical Program Manager will be responsible for the definition, documentation, maintenance, programmatic reporting and KPIs associated with the program objectives and policies. This role will participate in workflow development, training and applicable configuration within the UM/Care Management platform. The Clinical Program Manager will ensure all related initiatives meet all applicable state and/or federal regulatory requirements in addition to corresponding URAC/NCQA standards.

ROLE RESPONSIBILITIES

The Clinical Program Manager job description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Supports the strategic vision, manages the corresponding design for programs and coordination with other Bright member facing programs. (e.g., care navigation, case management, disease management and transitions of care)
  Identify and provide initial and ongoing reports on catastrophic, high dollar cases based on triggers from case management, utilization review, predictive modeling tool, and claims to the appropriate internal and external
• Trigger cases identified through the review of utilization review and claims reports to case management or chronic illness support staff to determine if case management or chronic illness support is warranted
• Manages the implementation of program, including the development of policies, workflows, training, and quality improvement processes.
• Facilitates, leads, and collaborates with cross-functional workgroups and organizational leaders, including, but not limited to
• Payment Integrity, Finance, Line of Business, Clinical Operations, and Market Performance in the ongoing review, management of program performance, and identification of opportunities for improvements to programs.
• Provide quality assurance and analysis of program design, efficacy, efficiency, and member/provider satisfaction as well as development of work plans to address performance improvement opportunities
• Collaborate with case management staff to ensure identification of and timely referral of transplant candidates to a designated Center of Excellence (COE). Ensure an access agreement is executed with the COE and all appropriate parties are informed regarding the pending transplant including case management, account manager, underwriting, the stop loss carrier and the Medical Directors
• Provide subject matter expertise at internal clinical and quality meetings, regulatory meetings, and any relevant community partner meetings, workgroups, etc.
• Keep current on new State and Federal Mandates and internal policies that affect managed care and ensure that internal policies and procedures comply
• Other duties and responsibilities as assigned

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• RN or related clinical licensure is preferred, but not required.
• Bachelor’s degree is required; relevant experience of five (5) or more years of experience will be considered in lieu of a degree.
• Prior experience with State and Federal regulatory and accreditation requirements is preferred.
• Four (4) years of experience with health care analytics, or driving clinical transformation initiatives with population health program in a Managed Care setting is highly preferred.
• Experience in interpreting data analytics, outcomes and measures in health care and use of that data to drive change is preferred.

PROFESSIONAL COMPETENCIES

• Ability to evaluate complicated problems and isolate contributing factors and develop solutions.
• Leads through influence and example.
• Good communication skills oral and written, ability to interact with others at multiple levels of the organization.
• Ability to develop strong cross-functional and collaborative relationship with internal and external partners, including the ability to work with a wide variety of people and personalities.
• Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative environment.
• Experience in using the Microsoft Office Suite including Excel and Word as well as demonstrated ability to learn/adapt to other computer-based systems and tools.

LICENSURES AND CERTIFICATIONS

• RN or another clinical licensure is preferred, but not required.

WORK ENVIRONMENT

The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Some travel may be required.