Clinical Account Manager, Consultant - Commercial

Your Role 

The Commercial CMO team works across multiple teams within Blue Shield to ensure smooth implementations for the commercial lines of business. The Program Manager Clinical Consultant, will report to the Regional Medical Director. In this role you will be responsible for working on premier accounts as part of the Commercial CMO team.   

Oversees clinical program management responsibilities for various commercial lines of business with a focus on premier accounts, working closely with medical management functional area teams, account management, medical directors, sales, and clients. This role will work cross functionally with sales, account management, vendors, medical directors, utilization management, and care management and mandates teams. 

Leverage clinical knowledge to liaison between internal and external stakeholders for our care management models. Support high profile client interactions using clinical knowledge to advise and resolve client escalations. Responsible for managing projects and business process improvement activities to ensure ongoing alignment with Blue Shield of CA's strategy and company objectives, as well as interdependencies of other business units. 

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work 

In this role, you will: 

• Provide clinical leadership and analysis for assigned projects/programs; ensure projects/programs meet BSC strategic objectives and contract requirements
• Lead in the face of uncertainty, change, and aggressive deadlines common to a rapidly growing company with an evolving business model
• Develop resourcing strategies to ensure optimum support for projects and for the day-to-day operational activities
• Proactively set and manage expectations to prioritize delivery and requirements, yielding consistent results
• Support and provide technical expertise in planning, execution, and leadership of programs, projects, and initiatives 
• Provide program reporting and status to Commercial CMO or designee
• Advise on access to care, letters of agreement, provider contracts, network gaps, denials, appeals and grievances, DMHC complaints, executive requests, reimbursement requests, accounts management and broker questions. 
• Collaborate with analytics, actuarial, and quality teams to develop, analyze, and distribute reports, and document program activities, interventions, and outcomes
• Perform deep-dive analysis of high-cost claims, vendor-identified population and other defined groups, producing case studies, reports and presentations
• Organize and lead cross-functional meetings, foster teamwork and collaborative problem-solving across diverse stakeholders
• Facilitate cost-of-care taskforces and recommend interventions at both macro and micro levels.
  Research industry best practices and care guidelines to support team initiatives and policy development.
• Provide insights into leading practices across BSC processes including medical policy, formulary, and care redirection/repatriation
• Develop and maintain project plans, KPIs, stakeholder maps, and documentation to support team goals and initiatives.
• Maintain a repository and an extensive working knowledge of relevant client-specific documents
• Support RFP responses, audits, presentations, and maintenance of program materials
   

Your Knowledge and Experience 

• Requires a bachelor’s degree or equivalent experience
• Requires at least 7 years of prior relevant experience
• Valid CA license in a clinical discipline such as RN, LVN, NP, PA, MSW, CPhT
• Exceptional communication and presentation skills 
• Ability to synthesize clinical data into a concise story
• Ability to think outside of the box and quickly problem solve
• Excellent analytical skills