Your Role

The Special Populations Unit (SPU) ensures effective oversight and monitoring of vulnerable groups identified by CalAIM, advancing equitable access to care and improving health outcomes. Through cross-functional collaboration and data-driven strategies, we advocate for inclusive, person-centered solutions that promote the well-being of those we serve.

The Program Manager Clinical, Principal will report to the Director of Special Populations Unit, Office of the Chief Medical Officer. Your role will focus on establishing strong collaboration and partnership with Utilization Management, Population Health Management (inclusive of Care Management, Transitional Care Services and Social Services), Behavioral Health and other clinical teams and assisting in the development of an oversight framework.

Your Work

In this role, you will:

• Establish SPU program goals and performance metrics to ensure effectiveness and alignment with organizational objectives
• Act as a clinical subject matter expert, providing guidance to stakeholders on program design and implementation
• Facilitate cross-departmental collaboration to drive alignment and integration of services
• Collect, analyze, and interpret clinical and operational data to assess program performance and impact
• Identify trends, develop improvement plans, and implement evidence-based interventions.
• Help develop a compliance framework to ensure Special Populations programs comply with federal, state, and local healthcare regulations, as well as accreditation standards.
• Monitor policy changes affecting special populations and adapt programs as necessary.
• Contribute to strategic planning efforts to ensure programs align with long-term organizational goals.
• Consult with all levels including senior management, make recommendations, and influence decision-making
• Leverage cross-functional internal and external relationships to drive initiatives forward
• Determine key business issues, develop effective action plans and implement to successful conclusion
• Lead with a collaborative approach and an understanding of existing resources and relationships between/among partner organizations while moving them towards constructive change

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires at least 10 years of prior relevant experience
• Minimum of 10 years of clinical experience, including experience working with special populations (e.g., Medicaid/Medicare patients, individuals with complex health needs, or underserved communities)
• Requires current, active California RN, NP, PA, LCSW, LPCC, or LMFT license
• 3-5 years Care Management experience in a health plan or other managed care setting preferred
• Excellent verbal and written communication style to drive positive outcomes
• Proficiency in data analysis, reporting tools, and healthcare technologies (e.g., electronic health records).
• Familiarity with quality improvement methodologies, such as Lean or Six Sigma
• Comprehensive understanding of healthcare regulations and accreditation standards, and payer programs (e.g., Medicaid, Medicare).
• Resourceful and collaborative: a team collaborator with strong listening skills and the ability to offer creative solutions to drive consensus
• Demonstrated cultural competence and a passion for serving diverse communities

Pay Range

The pay range for this role is: $ 136400.00 to $ 204600.00 for California.

Note

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.