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.

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:

• 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

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.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

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.

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.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.