Clinical Operation Project Manager

Key Responsibilities

• Demonstrate strong knowledge of health plan operations, particularly in the clinical and provider domains.
• Manage projects related to provider information, provider data, demographics, credentialing, contracting, fee schedules, provider hierarchies, and provider networks.
• Understand clinical policies, care management, assessments, care plans, satisfaction surveys, and member correspondence.
• Manage projects involving Utilization Management (UM), prior authorizations, clinical workflows, service channels, turnaround times, and regulatory policies.
• Understand HealthEdge GuidingCare and its application in healthcare and care management operations.
• Work with Electronic Health Records (EHRs) and clinical information systems.
• Understand healthcare enrollment processes, EDI files, claims adjudication, claims billing, and claims data systems such as FACETS.
• Manage projects involving pharmacy operations, pharmacy claims, formularies, and data exchange with Pharmacy Benefit Managers (PBMs).
• Understand provider vendor onboarding, extensions, and discontinuation processes.

• Understand CMS guidelines, state and federal regulations, compliance reporting, and contractual reporting requirements.
• Support Program Integrity functions and related reporting requirements.
• Understand HEDIS, Quality Management, healthcare equity, and Social Determinants of Health (SDOH).
• Work with Community-Based Organizations (CBOs), Health Information Exchange (HIE) functions, and Electronic Visit Verification (EVV) processes.
• Understand value-based reimbursement models and emerging healthcare trends.
• Coordinate reporting requirements and ensure proper documentation and communication across project teams.

• Manage medium- to high-complexity healthcare projects and standalone initiatives.
• Lead stakeholders in developing and refining project charters, objectives, scope, and deliverables.
• Develop and maintain project schedules, work breakdown structures, milestones, and project documentation.
• Track project progress against established plans and communicate status to stakeholders.
• Maintain RAID logs (Risks, Assumptions, Issues, and Dependencies).
• Identify and manage risks, issues, action items, decisions, and change requests.
• Develop mitigation strategies and contingency plans and escalate critical issues when necessary.
• Manage project scope, change control, and stakeholder expectations.
• Coordinate with System Integration Testing (SIT) and End-to-End User Acceptance Testing (UAT) teams.
• Develop project operations and support plans and coordinate production readiness activities.
• Prepare status reports, meeting minutes, decision documents, and project communications.
• Facilitate project meetings, weekly status updates, and steering committee discussions.
• Ensure project milestones and deliverables are completed and approved throughout the project lifecycle.

• Collaborate with business, clinical, and IT stakeholders to resolve blockers and drive timely project delivery.
• Coordinate with project management teams to present updates during stakeholder and steering committee meetings.
• Support state readiness reviews, including desk-based and onsite reviews, as required.
• Promote effective communication across business and technology teams.
• Coordinate project schedules, risks, issues, dependencies, and action items.
• Drive process improvements and enhance project management tools and practices.

Required Skills & Qualifications

• Strong experience as a Senior Project Manager in the healthcare or health plan domain.
• Extensive knowledge of healthcare clinical operations and care management.
• Experience with HealthEdge GuidingCare.
• Knowledge of provider data management, credentialing, contracting, and provider networks.
• Understanding of Utilization Management, prior authorizations, clinical policies, and EHRs.
• Knowledge of claims processing, pharmacy operations, PBM data exchange, and healthcare enrollment.
• Experience with healthcare compliance, CMS guidelines, and regulatory reporting.
• Strong project planning, risk management, scope management, and stakeholder coordination skills.
• Excellent written and verbal communication skills.
• Experience with ServiceNow and Azure DevOps (ADO) Boards.

Preferred / Good-to-Have Skills

• Experience with healthcare claims systems such as FACETS.
• Experience coordinating SIT and End-to-End UAT.
• Knowledge of project budgeting and financial tracking.
• Experience with HEDIS, Quality Management, SDOH, and value-based reimbursement.
• Experience with state readiness reviews and production operations readiness.