Job Description

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.

Responsibilities

Your Work
In this role, you will:

• Operate at a strategic business level to ensure projects/programs are in line with Blue Shield of California (BSC) strategic goals
• Consult with all levels including 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 enhancement
• 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

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.

About the Team

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.