Job Information
Tufts Health Public Plans Inc Program Manager II - Quality -Auditing and Monitoring - R7636 in Seattle, Washington
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. To learn more about who we are at Point32Health, click here{rel="nofollow" https:="" youtu.be="" s5i_hgoecjq="" ""="" target="" _blank""=""}.
Job Summary
The Program Manager II is responsible for projects and initiatives with significant cross-functional interface that support assigned programs. Responsibilities include managing major departmental programs with significant cross functional interface with moderate complexity, risk and/or cost. Responsibility may include development of new programs as well as management of ongoing programs. Changes to programs require some negotiation and change management skills to implement. By using knowledge of the company, the Program Manager II should be able to resolve most roadblocks to ensure success and progress. The Program Manager II should make recommendations for change by performing cost/benefit analysis and by using basic analytical and problem-solving capabilities to support the recommendation. Will also directly interact with Point32Health leadership.
Key Responsibilities/Duties -- what you will be doing
Manage ongoing Care Management (CM) and Utilization Management (UM) Oversight Program operations. This may include:
- Monitoring all relevant UM and/or Member Appeals and Grievances internal plan documents, processes, and systems against CMS Medicare, State contract, and State Medicaid Agency compliance requirements.
- Developing and maintaining the appropriate auditing, monitoring, and tracking tools.
- Performing auditing and monitoring of internal UM and/or Member Appeals and Grievances files.
- Analyzing audit results and collaborating with partnering business areas to identify and prioritize opportunities for improvement and implement action plans that meet Medicare and Medicaid program and health plan objectives.
- Working with multiple areas within the organization to ensure effective, accurate, timely processes and workflows.
- Participating in and assisting as needed with preparation for all internal and external audits, site visits, meetings (on or off-site) as assigned. External organizations may include but are not limited to CMS, State Medicaid agencies, and External Quality Review Organizations.
Perform detailed policy and impact analysis as it relates to oversight programs; make recommendations for process and/or policy change; present to various levels of the organization the findings and summary options. This includes determining data scope, consulting with Point32Health colleagues, performing analyses, and determining both quantitative and qualitative business implications. Collaborates with individuals and groups across the enterprise to develop new documents, processes, activities, systems, and initiatives in response to program compliance requirements, including data collection and analysis of documentation from various sources to meet program requirements.
Lead and/or manage projects and/or initiatives by representing program operations during planning and implementation phases. This may include:
Preparing written documentation associated with the program, including but not limited to pr