Program Manager, Consultant

Your Role The Behavioral Health Network Management, Healthcare Quality and Affordability (HQA) team is responsible for the development and maintenance of all Behavioral Health provider networks, including vendor relationships necessary to provide our members and clients with access to quality, affordable health care services. The Program Manager, Consultant will report to the Program Manager, Principal. In this role you will support the Behavioral Health Network Management, HQA team and be responsible for investigating and resolving claims issues through detailed root cause analysis, cross functional collaboration, and end to end remediation oversight. 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. Your Knowledge and Experience Requires a Bachelor's degree or equivalent experience Requires 7 years of prior relevant experience in Medicare claims processing and regulatory requirements; working with regulatory Behavioral Health (BH) requirements, audit readiness, documentation standards; BH claims analysis, issue investigation, and remediation oversight Requires Project Management experience Behavioral Health (BH) managed care experience of 5 years is preferred Experience with regulatory BH claims audits is preferred Experience researching BH claims for overpayments and fraud is preferred Experience with BH Policy & procedure development and auditing is preferred Knowledge of fundamentals of BH provider contracts Hybrid This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week. Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need. #J-18808-Ljbffr Blue Shield of CA