Clinical Program Manager

Valley Day & Night Clinic is seeking a highly skilled and knowledgeable Clinical Program Manager to oversee and manage all aspects of Medicare-related services within our family practice clinic. This role ensures compliance with Medicare regulations, optimizes reimbursement processes, and supports patient access to care.

The Clinical Program Manager is responsible for the strategic and operational management of the clinic’s Medicare Managed Care line of service. This role oversees care coordination, quality performance (HEDIS, STARS), RAF optimization, and payer relationships for contracts including WellMed, Cigna, BCBS, and others.

The Manager ensures alignment between clinical workflows, revenue cycle processes, and CMS quality metrics to improve patient outcomes and maximize reimbursement.

Key Responsibilities

• Lead the implementation and performance monitoring of all Medicare Advantage initiatives across multiple payer contracts.
• Analyze risk adjustment data and quality performance metrics; develop interventions to improve HCC capture and STARS ratings.
• Collaborate with providers, coders, and billing staff to ensure compliance with Medicare Advantage documentation and coding requirements.
• Coordinate with payers to ensure contractual obligations are met and incentive opportunities are pursued.
• Manage a care coordination team focused on panel management, preventative care, and chronic disease outreach.
• Develop dashboards and routine reports to track panel performance, missed opportunities, and clinical gap closures.
• Train clinical and administrative staff on best practices in Medicare Advantage operations.
• Represent the clinic in payer meetings, audits, and external reviews.
• Oversee the implementation and performance of Medicare Advantage initiatives across multiple payer contracts (WellMed, Cigna, BCBS, etc.).
• Ensure compliance with Medicare Advantage documentation, coding, and billing requirements.
• Represent the clinic in payer meetings, audits, and external reviews.
• Collaborate with providers, coders, and billing staff to align clinical documentation with CMS-HCC models.

Qualifications

• Minimum of 3 years of experience in Medicare administration, healthcare billing, or healthcare compliance. Preferred.
• Minimum of 3 years experience in supervision. Preferred.
• Strong knowledge of Medicare regulations, billing codes, and reimbursement procedures.
• Excellent organizational, communication, and problem-solving skills.
• Proficiency in electronic health records (EHR) and medical billing software.
• Ability to work independently and collaboratively in a fast-paced clinical environment.
• CPC or CRC certification a plus.
• Experience with QI reporting tools or dashboards (Power BI, Tableau, or similar).
• Bilingual (English/Spanish) preferred.
• RN or LVN preferred.
• Bachelor’s degree in Healthcare Administration, Nursing, or related field (or equivalent experience), preferred.
• Demonstrated knowledge of CMS-HCC model, STARS measures, and quality improvement frameworks.

The Benefits!

• Health Insurance
• Dental Insurance
• Vision Insurance
• 401(k)
• 401(k) matching
• Paid Time Off
• Employee discount
• Professional development opportunities

Salary: $50,000 - $70,000

Join us in delivering compassionate and comprehensive care to our community. If you have the necessary skills and certifications, we warmly encourage you to apply and become an essential member of our healthcare team.

Experience a rewarding career with a supportive team and excellent benefits. Apply today!