Blue Shield of California
Clinical Account Manager, Consultant - Commercial
🇺🇸Long Beach, California, United States4 days ago
MidFull TimeEN
Your Role
The Commercial CMO team works across multiple teams within Blue Shield to ensure smooth implementations for the commercial lines of business. The Program Manager Clinical Consultant, will report to the Regional Medical Director. In this role you will be responsible for working on externally facing health system accounts, business accounts, and special projects as part of the Commercial CMO team.
You will oversee various commercial lines of business with a focus on clinical program management responsibilities, working closely with medical care management functional area teams, quality, account management, medical directors, sales, vendors and clients.
Key components include leveraging extensive clinical knowledge to liaison between internal and external stakeholders to support successful performance. You will also support high profile client interactions using clinical knowledge and advanced data skills to advise and resolve Health System and client escalations. Additionally, you are responsible for managing projects and business process improvement activities to ensure ongoing alignment with Blue Shield of CA's strategy and company objectives, as well as interdependencies of other business units.
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:
Partner with medical groups to co-create programs encompassing a full spectrum of initiatives around disease management, complex care management, transitions of care and site of service, ensuring optimal utilization, access, and quality of care for members.
Develop resourcing strategies to ensure optimum support for projects and for the day-to-day operational activities
Identify opportunities around utilization, quality, and clinical initiatives: Work side by side with internal and external partners in the design and launch of clinical programs focused on high-risk members, hospital initiatives, and behavioral health as well as internal innovation programs
Provide program reporting, interventions and outcomes to Commercial CMO or designee
Collaborate with analytics, actuarial, and quality teams to develop, analyze, and distribute reports.
Perform deep-dive analysis of high-cost claims, vendor-identified population and other defined groups, producing case studies, reports and presentations
Organize and lead cross-functional meetings, foster teamwork and collaborative problem-solving across diverse stakeholders
Lead with a collaborative approach and an understanding of existing resources and relationships between/among partner organizations while moving them towards constructive change
Facilitate cost-of-care discussions, recommending interventions at both macro and micro levels.
Research industry best practices and care guidelines to support team initiatives and policy development to ensure best-in-class care for all members.
Develop and maintain project plans, KPIs, stakeholder maps, and documentation to support team goals and initiatives.
Maintain a repository and an extensive working knowledge of relevant Health System Dashboards, financial goals, performance improvement work plans and special projects.
Your Knowledge and Experience
Valid CA license in a clinical discipline such as RN, NP, PA
Typically, requires a college degree or equivalent experience and minimum 7 years of prior relevant experience
Requires previous health plan experience with understanding of Accountable Care Organizations (ACO), global versus shared risk financial arrangements, quality metrics and member experience. Experience in case utilization and utilization management and managed care delegated models is a plus.
In-depth understanding of data analytics with mastery of excel and an ability to use multiple data platforms for internal and external communication.
Strong PowerPoint application skills to create executive summaries and presentation decks.
Exceptional communication and presentation skills
Ability to synthesize clinical data into a concise story
Ability to think outside of the box and quickly problem solve
Excellent analytical skills
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
