Program Manager, Principal, Appeals & Grievances at Blue Shield of CA in Woodland Hills, California

Job Description:

Program Management -

Responsible for all aspects of program and project development involving cross-functional teams focused on delivery of internal products, programs or administrative systems. Oversees plans and directs schedules as well as budgets. Monitors programs/projects from initiation through delivery and interfacing with internal customers. Organizes activities and interdepartmental meetings; ensures communication facilitates completion of the program/project on schedule and within budget constraints. Applies Agile (SCRUM) or Waterfall methodologies to all programs and projects.

Program Manager - Responsible for managing the ongoing portfolio of projects to ensure ongoing alignment with Blue Shield of CA's strategy and company objectives, as well as interdependencies of other business units.

Responsibilities:

- Ability to operate at a strategic business level to ensures projects/programs are in line with Blue Shield of California strategic goals

- Ability to consult with all levels including senior management, make recommendations, and influence decision-making.

- Leverages cross-functional internal and external relationships to drive initiatives forward.

- Ability to effectively maneuver through organizational dynamics and tailor approach to ensure optimal outcome.

- Plans and implements multiple and extremely complex projects/programs spanning across business areas.

- Proven ability to determine key business issues, develop effective action plans and implement to successful conclusion.

- Ability to leverage Medicare and Medi-Cal Grievances and Appeals experience to ensure proper controls are in place.

- Support Regulatory audit activity including interactions with regulatory agencies.

- Work directly with Directors, Managers, Supervisors, business partners, etc. on recommendations to manage/avoid and mitigate risk.

- Reporting of risk, mitigation, needed controls to key stakeholders.

- Liaison with partner teams/leaders (ex: Customer Service, Pharmacy Benefits Manager, Claims, Utilization Management, etc.) to address gaps/controls on late routes, misroutes, receipt drivers, medical policy impact, overturn rates drivers, etc.

- Continuous review of processes and procedures and desk level procedures against current and proposed or new regulations.

- Interact with regulators.

- Support system implementation and changes.

- Other duties as assigned.

Organizational Impact

- Implements strategic goals established by functional leadership.

- Establishes operational plans for job area with direct short- to mid-term impact on results (e.g., 1-2 years).

- Provides measurable

- input into new products, processes, standards and/or operational plans that will have some impact on the achievement of overall function results.

Innovation & Complexity

- Responsible for proactively improving upon existing processes and systems using significant conceptualizing, reasoning and interpretation. Results may serve as precedent for future decisions.

- Problems and issues faced are numerous, and typically undefined where information is difficult to obtain. Conducts extensive investigation, critical thinking to understand root cause of problems. Problems span a wide range of difficult and unique issues across functions and/or businesses.

- Develops new perspectives and innovative approaches on existing or new problems.

- Applies agile methods.

Communication & Influence

- Communicates with parties within and outside of own job function.

- Has responsibilities for communicating with parties' external to the organization, which may include customers or vendors.

- Works to influence others to accept job function's view/practices, and agree to or accept new concepts, practices, and approaches.

- Requires ability to communicate with executive leadership regarding matters of significant importance to the organization.

- Generally, conducts briefings with senior leaders within the job function.

Leadership & Talent Management

- Frequently responsible for providing guidance, coaching and training to other employees across the company within area of expertise.

- Responsible for managing large, complex project initiatives of strategic importance to the organization, involving large cross-functional teams.

- May direct the work of other individual contributors and/or act as a cross-functional team lead.

Knowledge and Qualifications

-

- Technically proficient having broad background in problem solving tools. TQM, Six Sigma certification or Project Management certification preferred.

- Knowledge in developing and implementing company-wide, organizational development or process improvement programs.

- Knowledge of Blue Shield of CA or similar health care organization structure.

- Subject matter expert in sophisticated, best-practices organizational development, process improvement or project management processes.

- Strong negotiation skills and ability to successfully interact with all levels of management.

- Requires mastery level knowledge of job area typically obtained through advanced education combined with experience. May have deep knowledge of project management.

- Typically, requires a college degree or equivalent experience and minimum 10 years of prior relevant experience (including Appeals and Grievances, Medicare, Medi-Cal, Regulatory).

Additional Information

- Our Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!

- Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

- Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

- Requisition ID: 20002JF

- Posting Date: Nov 20, 2020

- Schedule: Full-time

.

Apply Now