Program Manager III

Program Manager III

The Program Manager III manages projects and initiatives critical to effective Medical Policy operations. Responsibilities include management of successful implementation of departmental and cross-functional projects to support Medical Policy operational goals, processes, and procedures. The PM III will lead activities needed to operationalize/stand up Medical Necessity Guidelines (MNGs) in a matrixed environment, including facilitating meetings with key contributors throughout the organization to support MNG implementation. The PM III performs detailed policy and impact analysis to support requirements needed to implement MNGs and make recommendations for functionality based on business partner input and industry guidance. The PM III resolves issues as needed post-MNG implementation. The Program Manager III will also interact with Medical Policy and Quality leadership and within Point32 Health to accomplish successful Medical Policy operational goals.

Key Duties/Responsibilities:

• Overall ownership and management of key processes within the Medical Policy Operations team, focusing on both on short-term initiatives and long-term strategic objectives.
• Lead and manage cross-functional projects and initiatives specific to Medical Policy growth and efficiencies; Provide downstream analysis and support of MNG development; Monitor MNG performance post-implementation.
• Proactive mitigation of possible program operations and integration issues; Utilize the ability to conceptualize and envision the impact of change; Propose process improvements/efficiencies to better meet the expectations of policy end-users and to satisfy regulatory requirements timely.
• Apply project management skills to ensure transparency, reporting, and successful outcomes; Cultivate and maintain relationships within Medical Policy and business partners.
• Ensure workflows, processes, risks, resources, and MNG quality are managed appropriately; The PM III will assess process needs through high-level gap analysis review and direct team members (PM IIs) as needed to implement process improvements.
• Identify risks, concerns, and/or issues and escalate to management as needed; Exercise judgment to make decisions within Medical Policy guidelines to ensure programs/projects are effectively progressing.
• Lead regular/ad-hoc cross-functional informational and/or working meetings, including effective agenda planning, facilitation, and tracking/follow-up on deliverables.
• Acts as a change manager and consultant regarding operational efficiencies; Applies industry knowledge such as medical necessity guidelines, claims processing, edits, medical coding, regulatory guidelines, and research.
• Other duties as assigned.

Education/Experience Requirements:

• 8-10 years business or industry experience preferably in a healthcare payer environment
• 5-8 years program/project management experience, including leading significant cross-functional, high-level initiatives
• Significant business process and program management experience related to the implementation of healthcare insurance business applications and/or medical policy management
• A proven ability to meet deadlines
• Bachelors degree required; Masters preferred

Skill Requirements:

• Ability to operate in a matrixed environment, including the aptitude to coordinate/encourage the participation of internal contacts to develop and/or maintain operational processes.
• Perform as an effective advocate for Medical Policy; Coach/mentor less experienced program managers.
• Proactively identifies conflict/integration issues and leads team members to parse/synthesize issues of the highest complexity; Ability to identify risks, embrace the big picture and has a proven ability to accurately assess resource allocation.
• Preferred detailed content knowledge of medical policy construction/management; Able to lead dialogue on subject with minimal direction.
• Ability to thrive in a matrixed, hands-on environment that demands a consultative and solutions-orientated approach that may span multiple operational areas.
• Possess outstanding communication and relationship management skills, including effectively managing challenging group dynamics to effectively reach positive outcomes.
• Possess high-level presentation skills, including the ability to interface with different levels of personnel.
• Flexible, proponent/champion for change, ability to conceptualize and envision the impact of change, and propose new methods of process improvements.

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.

This job has been posted by IgnyteAI on behalf of Point32Health. IgnyteAI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of IgnyteAI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law

Req ID: R7267