Program Manager, Senior - Medicaid & Medi-Cal

Overview
The Program Manager, Senior, Quality Improvement is responsible for the development and execution of targeted quality improvement initiatives in support of the Medi-Cal line of business. Responsibilities include contributing to improved performance on quality rating systems such as HEDIS, MCAS, CAHPS, NCQA Health Plan Ratings, DMHC HEQMS, and Medicaid QRS. The role includes designing, developing, and managing provider group quality interventions, toolkits, clinic days, and gathering analytic insights from quality data. The Program Manager aligns quality improvement initiatives with other lines of business (Commercial, Medicare) and ensures that current and future QI programs align with long-term organizational strategies.

In a results-oriented environment, the Program Manager will execute quality improvement efforts, incentive strategies, and new improvement tactics to bring additional value to integrated health benefits. This requires coordinating with internal cross-functional matrix teams as well as with clinical leadership and staff in provider organizations.

The Program Manager participates in project teams, works with external vendors, assigns and monitors work of team members, and provides guidance to ensure timely delivery of deliverables. This position may include limited accountability for managing budgets. In partnership with the Medi-Cal team, the role supports in-person clinic days across San Diego County held at Community Based Organizations and may require occasional evening and weekend commitments. The Program Manager builds strong, collaborative relationships with targeted provider organizations and develops communications about Blue Shield of California Promise Health Plan quality improvement initiatives through RFI responses, Medi-Cal contracts, toolkits, and other ad hoc assignments. Additionally, this position helps organize interdepartmental activities and has some operational responsibilities.

Responsibilities

Execute quality improvement efforts, incentive strategies, and new improvement tactics to improve performance on quality rating systems and related metrics.

Design, develop, and manage provider group quality interventions, toolkits, and clinic days; gather analytic insights from quality data.

Coordinate with internal cross-functional teams and clinical leadership to align QI initiatives with organizational strategy.

Participate in project teams, manage vendor relationships, and guide team members to ensure timely deliverables.

Manage budgets where applicable and support program governance and reporting.

Support in-person clinic days across San Diego County at Community Based Organizations, with possible evening/weekend commitments.

Build and sustain collaborative relationships with targeted provider organizations; communicate quality improvement initiatives and outcomes.

Hybrid/Field Work Schedule
This role is a hybrid field worker. The person is required to be in the San Diego office or visiting clinics 5 days per month minimum in the San Diego area. On average, there are 1–2 clinic days per week. Evening or Saturday hours may be required.

Your Knowledge and Experience

Requires a college degree or equivalent experience.

Minimum of 5 years of prior relevant experience.

At least 5 years of healthcare experience in Quality Improvement and Quality Management with knowledge in quality improvement, process improvement, and practice transformation techniques.

At least 5 years of Medicaid/Medi-Cal experience.

3 years working with IPAs, medical groups, FQHCs, and/or providers.

Previous project/program management experience.

Knowledge of HEDIS and accrediting body requirements (e.g., NCQA) desired.

Proficiency with Cozeva application highly desired.

Tableau for quality reporting is preferred.

Experience with review of medical records to identify service gaps and missed opportunities is preferred.

Hybrid- Field Worker
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need, in alignment with the hybrid workplace model (typically two days in office per week).

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