Program Manager

Job Summary The Program Manager, Consultant will report to the Program Manager, Principal and will support the Behavioral Health Network Management, Healthcare Quality and Affordability (HQA) team. The role involves investigating and resolving claims issues through detailed root cause analysis, cross‑functional collaboration, and end‑to‑end remediation oversight. Responsibilities Operate at a strategic business level to ensure projects and programs align with Blue Shield of California (BSC) strategic goals. Consult with executive leadership teams, make recommendations, and influence decision‑making. Leverage cross‑functional internal and external relationships to drive initiatives forward. Lead intake, investigation, and resolution of complex Behavioral Health (BH) provider‑reported claims issues, including escalations and system enhancements. Perform detailed root cause analysis of claim processing issues, partnering with Claims Operations, Configuration, Provider Operations, EDI, and other teams to identify underlying drivers. Manage project initiatives from initiation through delivery and oversight for continuous improvement. Identify patterns and trends in BH claims issues to inform process improvements, configuration changes, and control enhancements to prevent recurrence. Qualifications Bachelor’s degree or equivalent experience. 7 years of prior relevant experience in Medicare claims processing and regulatory requirements, including work with regulatory BH requirements, audit readiness, documentation standards, BH claims analysis, issue investigation, and remediation oversight. Project Management experience. Behavioral Health (BH) managed care experience of 5 years is preferred. Experience with regulatory BH claims audits preferred. Experience researching BH claims for overpayments and fraud preferred. Experience with BH policy & procedure development and auditing preferred. Knowledge of fundamentals of BH provider contracts. Hybrid Work Model This role requires employees to work from the office two days each week as part of the hybrid workplace model. Employees living more than 50 miles from an office location will work with their manager to determine in‑office time based on business need. Physical Requirements The position is primarily office‑based with a sedentary activity level most of the day. Employees may work from a home office/deskwork as needed. 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 the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard 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. #J-18808-Ljbffr