Clinical Program Manager, Enhanced Clinical Programs

Salary depends on experience
Posted on 10/31/17
Rancho Cordova, CA
8 - 10 years experience
Business Services
Salary depends on experience
Posted on 10/31/17


Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California’s Mission is to ensure all Californians have access to high-quality care at an affordable price. Blue Shield is focused on improving health care delivery by working closely with providers and making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 4 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than $325 million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.

We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone. 



The Clinical Program Manager, Enhanced Clinical Programs reports directly to the Sr. Manager of Enhanced Clinical Programs.  This position interfaces, supports and collaborates with the Sr. Director of Medical Policy (MD), Health Care Quality and Affordability operations directors/managers, product and benefits directors/managers, data analytics, information technology, business analysts and vendors.  The Clinical Program Manager is responsible for analyzing clinical, data and industry program trends, developing a business case for programs that enhance member care, quality, and improve Blue Shield’s stewardship of our members’ dollar.  The Clinical Program Manager is accountable for the successful implementation and ongoing tracking of program effectiveness and efficiency.  The Clinical Program Manager supports $160M+ in cost of healthcare targets for Medical and Payment Policy and is accountable for the identification and implementation of new programs to support ongoing CoHC savings.  This Clinical Program Manager is specifically responsible for:


  • Researching industry sources such as CMS, AHRQ, Hayes, NICE, and Blue Cross Blue Shield Association for emerging clinical and industry program trends; synthesizing that information into program opportunities, reviewing with clinical and operational leaders to formalize a clear program design.
  • Partnering with data analytics teams to identify outlier data trends of services and providers; synthesizing that information into program opportunities, reviewing with clinical and operational leaders to formalize a clear program design.
  • Building and leveraging industry and professional network relationships, including Blues partners, provider networks and specialty societies, for emerging clinical and industry program trends; synthesizing that information into program opportunities, reviewing with clinical and operational leaders to formalize a clear program design
  • Partnering with finance and actuarial teams, operational leaders and/or vendors to create a sound business case with business need, objectives, scope, program costs and program benefits and presenting to senior leaders for approval and/or funding
  • Development of an initiatives roadmap and tracking and monitoring of program performance against the business case to demonstrate value in enhanced member care quality and improved stewardship of member premiums
  • Development and refinement of the process by which enhanced clinical programs are brought from ideation to realization
  • Project management of internal implementations requiring staffing and/or process only.  Other program designs will be delivered to internal vendor management teams to implement
  • Participation in BCBSA forums and committees




Required knowledge, skills and experience for this role include the following:

  • Deep payor knowledge (8 +years) with a strong understanding of utilization management, contracting and benefits
  • Strong independent judgment, critical and analytical thinking, problem-solving and data-driven decision making skills
  • Ability to partner, collaborate with and influence relevant stakeholders, both internal and external.  Strong oral and written communication, relationship and consensus-building skills
  • Clinical experience, Registered Nurse (RN) or Physician Assistant (PA) preferable.
  • Strong clinical research skills
  • Strong professional networking skills
  • Demonstrated ability to drive to quality decisions with teams, peers and leaders.
  • Excellent Leadership/management skills, organization skills and facilitation skills
  • Experience with business case development and working with vendors
  • Strong understanding of the business of health care
  • Intermediate project management skills
  • Bachelor’s required, Masters preferred;
  • Registered Nurse (RN), preferable.
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