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Director, Clinical Program Management in Southfield, MI at AF Group

Date Posted: 8/22/2018

Job Snapshot

Job Description

COBX -Senior Health Services


The Director, Program Oversight provides direction and oversight for Medicare Advantage clinical programs for Senior Health Services and Visiant clients. This role is responsible for programs that will improve benefit cost management; improve the member experience and member outcomes; improve the gap between actual and assigned risk scores and improve the Stars scores. The role will integrate, align and grow the capabilities of programs across the continuum of care for HMO and PPO Medicare Advantage products. This role understands the business environment and service issues impacting the operating units, evaluates performance and makes necessary adjustments.


  • Demonstrate knowledge and experience in Medicare Advantage insurance product including but not limited to medical benefits, prescription drug benefits, risk adjustment, STAR program measurement, HEDIS measurement, product and benefit design, payment integrity, abuse/waste/fraud, regulatory compliance.
  • Work with Health Care Value staff to improve the delivery of services for members, both local and national, which are high quality and cost effective.
  • Work with multiple departments to assure member access to providers within contractual obligations.
  • Identify operational and financial impacts of proposed program and/or legislative changes
  • Presents strategic recommendations to leadership based on internal and external drivers and trends, support strategic initiatives and effectively manages and completes strategic objectives and department priorities.
  • Design, create, implement and manage an appropriate medical and care management program.
  • Conduct needs analyses, indentify gaps and develop program components to mitigate identified gaps.
  • Analyze existing best practices to create an innovative future state with BCBSA CMO's, NCQA, CMS etc., nationwide.
  • Through data analytics and data mining employ experts to analyze the data to determine potential needs and solutions.
  • Prepare regular progress, utilization, quality improvement and provider reports for executive management, BCBSM and BCN Chief Medical Officers and Board of Directors.
  • Champion the continued integration of Provider Driven Care Management and Member Directed Care Management initiatives.
  • Maintain effective, positive communication with the provider community.
  • Manage the administrative expense budget.


    Directly manages exempt and non-exempt staff. Carries out responsibilities in accordance with company policies and applicable laws. Responsibilities include interviewing, selecting and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints; and resolving problems.

    This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.



    Bachelors in human services or medical field required. Master's or Ph.D. level degree in a human services or medical field with licensure or certification preferred.


    Ten years of progressively more responsible operations or product support experience in a healthcare setting working with government products and programs, preferably Medicare, Demonstrated technical experience including strategic and tactical planning running care management programs, Medicare STARS programs; linking utilization review and utilization management programs; and applying quantitative analytics to determine potential needs and solutions to improve the quality and cost of care.


  • Detailed knowledge of government programs and products, preferably the Medicare program.
  • Demonstrated drive, determination, persistence and leadership ability to build and execute programs.
  • Extensive knowledge of laws, regulations, guidelines and compliance requirements related to provider relationships and quality programs.
  • Knowledge of team-building and employee motivation theories with the ability to effectively manage multi-functional employee teams.
  • Thorough knowledge of health insurance products and business operations.
  • Strong ability in quantitative analytics including using statistical analysis.
  • Demonstrated ability to work independently in the research, planning, development and implementation of corporate projects.
  • Ability to appropriately manage resources, budgets, issues, and risks.
  • Excellent oral and written communications, as well as presentation skills.
  • Ability to understand business needs and conceptualize and implement processes and products that support those business strategies.
  • Ability to comprehend the consequences of various problem situations and seek creative solutions.
  • Ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information, and respond to questions as appropriate.
  • Ability to establish rapport and maintain customer satisfaction without compromising priorities.
  • Ability to interact with others at all levels of the organization, to build consensus and get decisions implemented.
  • Thorough knowledge of project management principles and practices, including planning and coordination, with the ability to complete large projects involving multiple resources.
  • Ability to establish workflows, manage multiple projects, and meet necessary deadlines.
  • Ability to maintain confidentiality.
  • Ability to perform other assignments at locations outside the office.


    Work is performed in an office setting with no unusual hazards. Frequently required to travel and attend outside meetings with some overnight stays.

    The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

    We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.

    Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

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