Administrator Documentation, Business Processes, Clinical Competency, Continuous Improvement, Contract Requirements, Cross-Functional, Data Quality, Documentation Standards, Establish Priorities, Healthcare Administration, Interpersonal Skills, Leadership, Licensed Practical Nurse/Licensed Vocational Nurse, Licensing, Maintain Compliance, Microsoft Office, Nursing, Nursing Credentials, Operational Audit, Operational Improvement, Operational Support, Performance Analysis, Performance Management, Performance Metrics, Problem Solving Skills, Process Development, Process Management, Project/Program Management, Public Health, Registered Nurse (RN), Regulatory Compliance, Relationship Management, Reporting Dashboards, Reporting Skills, Requirements Management, Research Skills, Sales Management, Service Level Agreement (SLA), Social Work, Time Management, Trend Analysis, Utilization Management, Utilization Review Accreditation Commission (URAC), Vendor/Supplier Evaluation, Vendor/Supplier Quality Management, Vendor/Supplier Selection
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Job Summary
The Manager of Clinical Program Management and Vendor Performance will compile reporting related to the performance and continuous improvement of Utilization Management (UM), Care Management (CM) and vendor programs. This role collaborates across clinical, operational and analytic teams for all lines of business to ensure compliant and high quality member centered outcomes. The Manager supports program monitoring, reporting, vendor performance management, and execution of internal operational improvements and vendor oversight for compliance requirements.
Requirements
EDUCATION
Bachelor's degree in healthcare administration, public health, social work or related field required.
Master's degree in nursing preferred.
LICENSING/CERTIFICATION
Clinical licensure such as Registered Nurse (RN), Licensed Practice Nurse (LPN), and/or Social Work (SW) preferred.
Knowledge of Utilization Review Accreditation Commission (URAC) Utilization Management/Care Management standards preferred.
EXPERIENCE & KNOWLEDGE
Minimum seven (7) years' experience Utilization Management or Care Management OR applicable master's with minimum five (5) years' experience.
Minimum two (2) years' leadership experience (team, role, and/or project management).
Minimum of two (2) years demonstrated experience in reporting or dashboarding for program management to track key performance indicators.
Experience managing or working with external vendors preferred.
Strong knowledge of Utilization Management or Care Management workflows, documentation standards, and care coordination processes.
Knowledge of Utilization Review Accreditation Commission (URAC) Utilization Management/Care Management standards preferred.
ESSENTIAL ABILITIES
Demonstrated critical thinking and sound judgment.
Ability to interpret performance data, identify trends, and develop actionable recommendations.
Ability to lead requirements development and collaborate with data team to develop reporting and dashboarding for program monitoring.
Skills
- Business Process Development
- Critical Thinking
- Cross-Functional Collaboration
- Data Reporting
- Documentations
- Facilitation
- Interpersonal Communication
- Leadership
- Microsoft Office
- Organizational Compliance
- Organizing
- Prioritization
- Relationship Management
- Setting Performance Standards
Responsibilities
- Collaborates with analytics and business teams to maintain and improve dashboards and reporting tools.
- Conducts research and assists with workflow assessments to support operational improvements.
- Ensures program compliance with regulatory, contractual, and audit expectations, including Utilization Management/Care Management standards.
- Facilitates recurring vendor meetings, prepares agendas, documents updates, and drives follow‑up actions.
- Facilitates Utilization Management and Care Management Oversight Committee meetings and participates in Stakeholder Oversight Committee meetings to deliver UM and CM performance reporting.
- Facilitates working sessions with stakeholders to resolve program and process challenges.
- Identifies barriers to vendor or program performance and partners with internal teams and vendors to address and resolve issues.
- Implements a quarterly vendor performance program for Utilization Management and Care Management programs, serving as the primary operational point of contact.
- Monitors vendor adherence to Service Level Agreements (SLAs), Key Performance Indicators (KPIs), and contractual requirements and supports timely resolution of issues/complaints.
- Prepares summaries of program performance, risks, and operational recommendations for leadership.
- Reviews and analyzes internal and vendor program data to identify performance trends, risks, and improvement opportunities.
Certifications
Registered Nurse (RN) - Arkansas State Board of Nursing
Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Employment Type
Regular
ADA Requirements
1.1 General Office Worker, Sedentary, Campus Travel - someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.
B
Blue Cross and Blue Shield Association
At the Blue Cross and Blue Shield Association (BCBSA), we provide business strategy, technical support and consulting expertise to 36 Blue Cross and Blue Shield companies across the nation, employing more than 1,000 of the best strategic thinkers in the industry. We are a Brand manager that sets quality control standards for the 36 independent companies that use the Blue Cross and Blue Shield Brands, and we serve as a trade association that represents these Blue companies. It is through our involvement that the Blues companies share a united vision and strategy while also benefiting from the local strength of all member companies.