Clinical Program Manager (44429)

The Clinical Program Manager is responsible for the strategic design, implementation, and ongoing management of clinical programs within the health plan to improve quality, member outcomes, regulatory compliance, and cost-effectiveness. This role leads and supports the collection, analysis, and reporting of data and the development of intervention strategies in support of advancing the organization's clinical strategy. This position supports program development, monitoring, and evaluation of programs to drive evidence-based decision making in collaboration with internal stakeholders such as product, care management, pharmacy, quality and behavioral health and external stakeholders such as providers, community organizations and state agencies. The Clinical Program Manager provides regular reporting to committees and leadership to highlight progress and ensure alignment with company initiatives and goals. Works both independently and collaboratively, compiling and analyzing complex data and information to provide meaningful results, identify success factors and improvement opportunities, suggest potential solutions, and help internal customers set strategic direction. The Clinical Program Manager should bring intellectual curiosity, proven data analytics skills, and problem-solving to deepen insights into the factors that drive health care quality, costs, and equity.

Duties and ResponsibilitiesResponsibilities include, but are not limited to the following:

Clinical Program Leadership

• Lead the development, implementation, and optimization of clinical programs across medical, pharmacy, and population health domains
• Translate clinical evidence, guidelines, and regulatory standards into operationally effective programs and workflows.
• Serve as the clinical subject matter expert for assigned programs, ensuring alignment with best practices, accreditation standards (e.g., NCQA, CMS), and state and federal regulations.
• Analyze available industry data, trends, and best practices to leverage for organization clinical strategy development
• Facilitate meetings, develops and delivers progress reports, proposals, requirements, presentations and other documentation
• Support the department's leadership team for operational work as well as larger scope activities, including, but not limited to, writing department annual reports and ad hoc requests, developing and maintaining department dashboards, and performing department audits
• Identify and communicate risk areas and barriers that could inhibit the organization's ability to achieve clinical program goals
• Map out Program Strategy and oversee Performance Management
• Define program goals, success metrics, KPIs, and outcome measures, including quality, utilization, member experience, and financial performance.
• Monitor program performance through data analysis, dashboards, and reporting; identify opportunities for improvement and lead clinical program corrective action plans.
• Partner with Analytics teams to ensure appropriate data capture, measurement, and evaluation of program effectiveness.

Program Oversight

• Develop and maintain program policies, procedures, and workflows to support consistent, compliant clinical program development, implementation and monitoring.
• Support vendor selection, implementation, and oversight, including performance monitoring and contract deliverables.
• Gather and analyze data to support decision-making and program measurement. Evaluates trends to identify and implement changes in process and policy to improve financial and quality outcomes
• Provide updates to leadership on program effectiveness, providing recommendations for initiating, enhancing or terminating programs.
• Oversee provider based clinical programs such as but not limited to delegated programs.

Other:

• Represent Neighborhood at community forums related to clinical programs
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Required:

• Active, unrestricted clinical license in the state of Rhode Island:

• Registered Nurse (RN) or

• Doctor of Pharmacy (PharmD)

• Five (5) + years' experience working in healthcare, with substantial knowledge of the health system and provider environment

• Demonstrated experience designing, implementing, and managing clinical programs.

• Strong understanding of care management, quality programs, and population health management.

• Experience working with health care analytics, regulatory requirements, and project management

• Experience working with statistical analysis of complex health care data sets, including health care claims and health outcomes data, to support improvement activities

• Proven ability to analyze data, interpret trends, and translate insights into actionable program improvements.

• Demonstrated ability to develop written reports inclusive of qualitative and quantitative analysis outlining conclusions and recommendations for improvement

• Excellent interpersonal skills, including the ability to work across the organization and externally and to interact, influence and negotiate effectively at all levels of management

• Ability to work independently with minimal supervision

• Effective communication skills, both verbal and written

• Outstanding time management and organizational skills

• Demonstrated ability to manage multiple initiatives simultaneously in a deadline driven environment

• Proficiency in Microsoft Office

Preferred:

• Graduate degree in public health, policy, heath care, or other related field
• Community experience in organizing or supporting at-risk and vulnerable populations
• Proficient in using Power BI.
• Experience working in a managed care environment with focus on health care analytics and quality improvement requirements
• Previous work experience in the analysis and interpretation of health care data, such as health care claims data, public health surveillance data, health survey data and clinical data abstracted from medical records
• Knowledge of medical coding systems used for diagnoses, procedures, pharmaceuticals and clinical laboratory data

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.