Program Manager, Principal

Your Role

The Appeals and Grievances team helps our members with their concerns, ensures compliance and supports audit activity. The Program Manager, Principal will report to the Sr. Director of Grievances and Appeals. In this role you will support the systems and system changes leveraged by the Appeals and Grievances team, and ensure the implementation, testing, changes and oversight (including vendor oversight) of behavioral health care is managed effectively. You will also be responsible for supporting compliance, regulatory audit activity, inventory management, addressing drivers of inventory, and vendor oversight impacting behavioral health. 

Your Work

In this role, you will:

• Operate at a strategic business level to ensure projects/programs impacting behavioral health are in line with Blue Shield of California strategic goals  
• Consult with all levels including senior management, make recommendations, and influence decision-making
• Leverage cross-functional internal and external relationships to drive behavioral health initiatives forward 
• Plan and implement multiple and extremely complex projects/programs spanning across business areas
• Determine key business issues impacting behavioral health, develop effective action plans and implement to successful conclusion

• Lead and document internal/external meetings

• Facilitate monthly system testing

• Address current and future state needs

• Conduct meetings and oversight of vendors

• Support transformation activity

• Support compliance and regulatory audit activity impacting behavioral health

• Support inventory management and address root cause analysis of inventory fluctuations

Your Knowledge and Experience

• Requires a bachelor’s degree or equivalent experience

• Requires at least 10 years of prior relevant experience

• Requires at least 5 years Appeals and Grievances experience 

• Behavioral health knowledge and experience preferred, including behavioral health provider type and service knowledge, professional and facility and Applied Behavioral Analysis (ABA) and across all commercial and government lines of business

• Requires experience in Appeals and Grievance system change, implementation and vendor oversight

• Requires advanced experience in risk mitigation, problem solving and analysis as well as preparing and presenting related materials