Job Information
Tufts Health Public Plans Inc Program Manager III - Quality - Delegated Provider Oversight - R7644 in Seattle, Washington
Who We Are
Point32Health 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{rel="nofollow" https:="" youtu.be="" s5i_hgoecjq="" ""="" target="" _blank""=""}.
Job Summary
The Delegated Provider Oversight Program Manager (Program Manager) manages programs and projects with significant complexity, risk and/or cost that support assigned programs and providers delegated for Utilization Management (UM) and/or Care Management (CM) activities. Key responsibilities include medium to large scale projects and initiatives. Responsibilities include successful implementation of large cross-functional projects to support the program(s), working closely with the appropriate Point32Health staff and external stakeholders to manage programs/projects, performing thorough and detailed policy and impact analysis, leading and/or representing the program in change initiatives that affect multiple departments. The Program Manager evaluates the cost and feasibility of multiple options/alternatives to resolve program issues and to make recommendations on those issues that best meet program and corporate Point32Health, as well as objectives. Change to ongoing programs at this level will usually require facilitating cross-departmental meetings as well as negotiations with outside parties/partners and contacts to explain and justify the impact. The Program Manager will also interact directly and regularly with leadership within the department and within Point32Health and others to accomplish successful program management.
Key Responsibilities/Duties -- what you will be doing
• Overall program management of Care Management (CM) and Utilization Management (UM) Oversight Programs, focusing on both short-term initiatives and long-term strategic direction and objectives for the programs. The Program Manager is responsible for: o Leading day-to-day operations relating to providers delegated for Medicare and Medicaid applicable UM and/or CM activities. o Collaborating with individuals and groups across the enterprise and externally on new/existing documents, processes, activities, systems, and initiatives in response to program compliance requirements. Includes data collection and analysis of documentation from various sources to meet program requirements. o Providing operational oversight through regular communication, education and design of programs and strategies to assist delegated providers with meeting Point32Health expectations and CMS Medicare and State Medicaid compliance requirements. o Participating in and assisting as needed with preparation for all internal and external audits, site visits, meetings (on or off-site) as assigned. External organizations may include but are not limited to CMS, State Medicaid agencies, and External Quality Review Organizations. o Proactive and solutions-oriented management of program operations and integration issues, requiring the ability conceptualize and envision the impact of change, and propose new ways to do business to better meet the needs of the client/partner and Point32Health o Management of delegated providers' preparation and delivery of documents and data to meet Point32Health requirements and CMS Medicare