Clinical Account Manager, Consultant - Commercial

Job Description

The Commercial CMO team works across multiple teams within Blue Shield to ensure smooth implementations for the commercial lines of business. The Program Manager Clinical Consultant, will report to the Regional Medical Director. In this role you will be responsible for working on externally facing health system accounts, business accounts, and special projects as part of the Commercial CMO team.

You will oversee various commercial lines of business with a focus on clinical program management responsibilities, working closely with medical care management functional area teams, quality, account management, medical directors, sales, vendors and clients.

Key components include leveraging extensive clinical knowledge to liaison between internal and external stakeholders to support successful performance. You will also support high profile client interactions using clinical knowledge and advanced data skills to advise and resolve Health System and client escalations. Additionally, you are responsible for managing projects and business process improvement activities to ensure ongoing alignment with Blue Shield of CA's strategy and company objectives, as well as interdependencies of other business units.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

In this role, you will:

• Provide clinical leadership and data analysis for assigned projects/programs; ensure projects/programs meet BSC strategic objectives and contract requirements.
• Lead in the face of uncertainty, change, and aggressive deadlines common to a rapidly growing company with an evolving business model
• Partner with medical groups to co-create programs encompassing a full spectrum of initiatives around disease management, complex care management, transitions of care and site of service, ensuring optimal utilization, access, and quality of care for members.
• Develop resourcing strategies to ensure optimum support for projects and for the day-to-day operational activities
• Proactively set and manage expectations for expectations of delivery and requirements, yielding consistent results
• Support and provide deep data analysis to plan, execute, and lead programs, projects, and initiatives
• Identify opportunities around utilization, quality, and clinical initiatives: Work side by side with internal and external partners in the design and launch of clinical programs focused on high-risk members, hospital initiatives, and behavioral health as well as internal innovation programs
• Provide program reporting, interventions and outcomes to Commercial CMO or designee
• Collaborate with analytics, actuarial, and quality teams to develop, analyze, and distribute reports.
• Perform deep-dive analysis of high-cost claims, vendor-identified population and other defined groups, producing case studies, reports and presentations
• Organize and lead cross-functional meetings, foster teamwork and collaborative problem-solving across diverse stakeholders
• Lead with a collaborative approach and an understanding of existing resources and relationships between/among partner organizations while moving them towards constructive change
• Facilitate cost-of-care discussions, recommending interventions at both macro and micro levels.
• Research industry best practices and care guidelines to support team initiatives and policy development to ensure best-in-class care for all members.
• Develop and maintain project plans, KPIs, stakeholder maps, and documentation to support team goals and initiatives.
• Maintain a repository and an extensive working knowledge of relevant Health System Dashboards, financial goals, performance improvement work plans and special projects.

Qualifications

Your Knowledge and Experience

• Valid CA license in a clinical discipline such as RN, NP, PA

• Typically, requires a college degree or equivalent experience and minimum 7 years of prior relevant experience

• Requires previous health plan experience with understanding of Accountable Care Organizations (ACO), global versus shared risk financial arrangements, quality metrics and member experience. Experience in case utilization and utilization management and managed care delegated models is a plus.

• In-depth understanding of data analytics with mastery of excel and an ability to use multiple data platforms for internal and external communication.

• Strong PowerPoint application skills to create executive summaries and presentation decks.

• Exceptional communication and presentation skills

• Ability to synthesize clinical data into a concise story

• Ability to think outside of the box and quickly problem solve

• Excellent analytical skills

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

About Us

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.

• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.

• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

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.

Please click here for further physical requirement detail.

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.

Job Info

• Job Identification 20260917
• Job Category Business Operations
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