The Program Manager will partner closely with clinical leaders, physicians, nurses, care managers, operations teams, analytics teams, and client stakeholders to improve member outcomes, optimize healthcare utilization, and enhance operational efficiency.
Job title:Program Manager - Clinical Operations
Job Description:Position SummaryThe Program Manager - Clinical Operations is responsible for leading strategic programs and operational initiatives supporting Care Management, Utilization Management, Care Coordination, Population Health, and Value-Based Care services. This role will drive program execution, operational excellence, quality improvement, and performance outcomes across clinical operations while ensuring alignment with organizational goals and client expectations.
The Program Manager will partner closely with clinical leaders, physicians, nurses, care managers, operations teams, analytics teams, and client stakeholders to improve member outcomes, optimize healthcare utilization, and enhance operational efficiency.
Key ResponsibilitiesProgram Leadership & Execution- Lead end-to-end management of clinical operations programs, including planning, implementation, monitoring, and optimization.
- Manage multiple workstreams supporting care management, utilization management, transitions of care, chronic disease management, and population health initiatives.
- Establish program governance, project plans, milestones, and performance metrics.
- Ensure timely delivery of strategic initiatives while meeting quality, operational, and financial objectives.
Clinical Operations Management- Collaborate with clinical leadership to improve care management workflows and operational processes.
- Drive initiatives focused on reducing avoidable admissions, readmissions, emergency department utilization, and total cost of care.
- Support implementation and enhancement of clinical programs targeting high-risk and complex populations.
- Ensure operational readiness for new client implementations, program expansions, and process transformations.
Population Health & Value-Based Care- Support value-based care initiatives through performance monitoring and outcome improvement strategies.
- Utilize healthcare analytics to identify care gaps, risk trends, utilization patterns, and intervention opportunities.
- Partner with quality and clinical teams to improve HEDIS, STAR, and other quality performance measures.
- Monitor key population health metrics and recommend improvement actions.
Stakeholder & Client Management- Serve as a primary point of contact for internal and external stakeholders.
- Facilitate collaboration across clinical, operational, technology, quality, and analytics teams.
- Present program performance, operational updates, risks, and recommendations to leadership and clients.
- Build strong relationships with healthcare payer, provider, and care management stakeholders.
Quality & Regulatory Compliance- Ensure adherence to NCQA, CMS, HIPAA, URAC, and client-specific requirements.
- Support audit readiness and regulatory compliance activities.
- Monitor operational quality metrics and implement corrective action plans when necessary.
- Promote a culture of continuous quality improvement.
Performance Management & Analytics- Develop and monitor KPIs, operational dashboards, and program scorecards.
- Analyze trends related to productivity, utilization, quality outcomes, and member engagement.
- Identify opportunities for operational optimization through data-driven decision-making.
- Provide executive-level reporting and actionable insights.
Risk & Change Management- Identify program risks, operational challenges, and process gaps.
- Develop mitigation strategies and manage change initiatives across teams.
- Ensure effective communication and stakeholder engagement throughout program implementation.
Required Qualifications- Bachelor's degree in Healthcare Administration, Nursing, Public Health, Life Sciences, Business Administration, or a related field.
- 7+ years of experience in healthcare operations, care management, utilization management, population health, or clinical program management.
- 3+ years of experience leading cross-functional programs or large-scale operational initiatives.
- Strong understanding of healthcare payer and provider operations.
- Experience working with clinical and operational performance metrics.
Preferred Qualifications- Master's degree (MBA, MHA, MPH, MSN, or equivalent).
- PMP, Lean Six Sigma, PMP, or Healthcare Quality certifications.
- Experience with Value-Based Care, Risk Adjustment, Population Health Management, HEDIS, STAR Ratings, or Care Management programs.
- Familiarity with EMR/EHR systems, care management platforms, and healthcare analytics tools.
Core Competencies- Program & Portfolio Management
- Clinical Operations Leadership
- Population Health Management
- Utilization & Care Management
- Value-Based Care Strategy
- Healthcare Analytics & Reporting
- Process Improvement & Operational Excellence
- Stakeholder & Client Management
- Regulatory Compliance
- Change Management
- Strategic Thinking & Problem Solving
Key Performance Indicators (KPIs)- Program delivery within scope, timeline, and budget.
- Improvement in care management and utilization outcomes.
- Reduction in avoidable admissions and readmissions.
- Enhanced quality measure performance (HEDIS, STAR, CMS metrics).
- Client satisfaction and operational performance targets.
- Operational efficiency and productivity improvements.
- Compliance and audit readiness outcomes.
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