Enable America Jobs

"Who We ArePoint32Health 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 SummaryThe 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 doingEstablishes 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 jobEducation, Certification and LicensureBachelor’s degree in nursing or related field requiredRegistered Nurse with current unrestricted license requiredMaster’s degree in healthcare related field preferredCertified Professional in Healthcare Quality (CPHQ) and / or Certified Case Manager (CCM) preferredExperience (minimum years required):5 or more years’ experience in a clinical setting requiredExperience in care management in a provider setting and/or managed care setting is highly desirableLeadership of programs / projects with an accreditation/compliance/regulatory focus is preferred, preferably in a managed care or related health care environmentExperience 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 preferredSkill RequirementsAbility to work in a matrix environment with minimal supervisionExcellent verbal and written communication, and active listening skillsExcellent interpersonal skillsStrong clinical and critical thinking skillsExcellent presentation skills including ability to interface effectively with external contactsAbility to exercise sound clinical judgment and raise issues to appropriate management for resolutionAbility to conceptualize the impact of change and propose new methods of conducting businessAbility to use analytical skills to develop new or implement change to existing program functionsAbility to perform quantitative and qualitative data analysis and reportingAbility to interpret and explain the implications of planned changes to current state business unitsAbility to problem solve and overcome obstacles to ensure successful program operationsMust have commitment to excellence in customer serviceAbility to solve complex issues and identify creative, transformative solutionsProficiency with MS Office applications (Word, Excel, PowerPoint)Ability to utilize multiple applications simultaneouslyA proven ability to meet deadlines is also required.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.DisclaimerThe 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.Compensation & Total Rewards OverviewAs part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:Medical, dental and vision coverageRetirement plansPaid time offEmployer-paid life and disability insurance with additional buy-up coverage optionsTuition programWell-being benefitsFull suite of benefits to support career development, individual & family health, and financial healthFor more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.PDN-9c4f3193-969e-449c-ba46-70d66c0fa768"