We are seeking an experienced Senior Project Manager with a strong background in healthcare, clinical operations, and health plan administration. The ideal candidate will have expertise in provider information and provider data management, care management, utilization management, and clinical policy.
Candidates should have hands-on experience working with HealthEdge GuidingCare, Electronic Health Records (EHRs), and healthcare systems such as FACETS. The role involves managing cross-functional healthcare projects, coordinating business and IT stakeholders, overseeing project delivery, and ensuring compliance with state and federal healthcare regulations.
The ideal candidate must possess excellent communication, stakeholder management, risk management, and project planning skills.
Position: Senior Project Manager (Sr. PM)
Location: 100% Remote
Start Date: October 26, 2026
Industry: Healthcare / Health Plans
Required Experience: Strong healthcare project management experience with Clinical Operations and HealthEdge GuidingCare.
Key Responsibilities
1. Healthcare & Clinical Operations
- 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.
2. Healthcare Compliance & Quality
- 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.
3. Project Management & Delivery
- 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.
4. Stakeholder & Team Coordination
- 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.
