The Program Manager is responsible for developing, implementing, managing, and evaluating strategic initiatives that support the Complaints & Grievances operation. This role serves as a business lead and system owner for C&G-related programs, technology solutions, and operational initiatives, ensuring alignment with CMS, NCQA, contractual, and organizational requirements. The Program Manager partners with operational, compliance, technical, and business stakeholders to drive process improvements, manage projects, support regulatory compliance, and optimize the member and provider experience.
The Program Manager supports departmental leadership and is recognized as a subject matter expert and lead resource across the organization. This position will manage relevant support staff and is expected to operate effectively within a highly matrixed environment.
This is a full-time position working Monday through Friday daylight hours. This is a remote position, but you will be required to go into the office on a needed basis which is located in Pittsburgh, PA.
Responsibilities: - Manage various programs, projects, initiatives, campaigns, and events related to Complaints & Grievances operations, regulatory compliance, and system optimization.
- Serve as the business owner for C&G-related systems, ensuring functionality supports accurate intake, processing, investigation, decisioning, correspondence, reporting, and resolution activities.
- Collaborate with operational, compliance, clinical, technology, and business stakeholders to identify needs, prioritize initiatives, and deliver effective solutions.
- Work with internal and external customers to provide relevant deliverables, including business requirements, project plans, operational documentation, contracts, and regulatory support materials as needed.
- Define, maintain, and execute project plans while ensuring milestones and deadlines are achieved.
- Lead user acceptance testing (UAT), regression testing, validation activities, and production readiness reviews for system enhancements and implementations.
- Develop, implement, and maintain policies, procedures, workflows, and operational guidelines that support regulatory compliance and business objectives.
- Translate business, operational, and regulatory requirements into actionable specifications and deliverables for technical and operational teams.
- Coordinate activities across multiple departments to ensure projects, system enhancements, and operational initiatives are successfully implemented and communicated.
- Evaluate program effectiveness through analysis of key performance indicators, audit findings, operational performance metrics, user feedback, and business outcomes.
- Summarize, interpret, and communicate program results, trends, risks, and recommendations to leadership and stakeholders.
- Create and deliver senior-level presentations regarding system performance, operational initiatives, regulatory risks, enhancement priorities, and strategic opportunities.
- Design and develop project plans for new initiatives, including operational workflows, implementation strategies, business requirements, training materials, communication plans, and process documentation.
- Manage competing priorities and enhancement requests by assessing regulatory impact, operational risk, member experience implications, and business value.
- Support resource planning and prioritization across multiple projects and operational workstreams.
- Create and deliver training and educational materials related to system functionality, operational processes, compliance requirements, and new initiatives.
- Utilize reporting, analytics, and operational data to identify trends, support root cause analysis, and inform continuous process improvement efforts.
- Partner with business owners and leadership to develop remediation plans, corrective actions, and strategic solutions in response to audits, findings, operational challenges, or regulatory changes.
- Monitor changes in CMS, NCQA, state, federal, and contractual requirements and ensure programs, processes, and system functionality remain aligned.
- Facilitate coordination with vendors, external reviewers, and third-party partners, including integration efforts and operational support initiatives.
- Act as a change agent by promoting adoption of new processes, technologies, and program improvements.
- Provide leadership, guidance, and oversight to assigned staff and project resources, as applicable.
- Support the Program Director and departmental leadership in achieving strategic objectives and organizational priorities.
- Perform in accordance with system-wide competencies and behaviors.
- Perform other duties as assigned.
Qualifications: - Masters degree in health administration or related health field preferred; or Bachelors degree with demonstrated successful experience in clinical program administration and/or other health related discipline.
- Strong leadership and interpersonal skills; Management experience preferred.
- Strong computer skills, including proficiency in Microsoft Office, Word and Excel.
- Excellent oral and written communication skills.
- Excellent organizational and analytical skills.
- Financial analytic skills preferred.
- A minimum of five to seven years of applicable experience in health care delivery is required.
- 3 years in health care insurance preferred.
- Candidate must demonstrate excellent written and oral communication skills.
- Must be able to interact and negotiate with all facets of the wellness industry.
- Excellent planning, documentation, organizational, analytical and problem solving skills are also required.
- Candidate must demonstrate leadership and project management skills.
- Ability to map re-engineering processes to positively impact productivity in terms of timeliness and accuracy.
- Ability to work with and take direction from Senior Management.
- Desire to continue upward progression within organization
