B

Blue Shield of California

California nonprofit health insurance provider

Program Manager Clinical - Consultant-Cost of Healthcare Analysis

Full-Time
$111.5k - $188.7k
Senior
Bachelor's
Lodi, CA, USA+8 moreMore locations: Redding, CA, USA | Long Beach, CA, USA | California, USA | Rancho Cordova, CA, USA | Woodland Hills, Los Angeles, CA, USA | Oakland, CA, USA | El Dorado Hills, CA, USA | San Diego, CA, USA
HybridVirtually full-time; office attendance may be required based on business need.
Project & Program ManagementProgram Management

About the job

Requirements
  • A bachelor's degree, or a high school diploma/GED plus four years of additional relevant experience in lieu of a degree and completion of an accredited educational program that meets applicable professional-license requirements.
  • At least seven years of prior relevant experience.
  • A current California LVN, RN, NP, or PA license.
  • Strong organizational or project management skills and the ability to self-start and own end-to-end taskforce activities.
  • Strong written and oral communication skills and the ability to facilitate cross-functional discussions and lead teams through influence to drive actions and outcomes.
  • Strong proficiency with data visualization and analytical tools such as Power BI and other reporting platforms.
  • Experience working with employer fully insured and self-insured populations, large group accounts, and multidisciplinary stakeholder groups.
Responsibilities
  • Provide analysis, leadership, and guidance for a line of business, including identifying opportunities, creating business cases, and supporting implementation.
  • Provide leadership amid uncertainty, change, and aggressive deadlines in an evolving business model.
  • Create presentations and manage meeting requests.
  • Lead cross-functional meetings, foster teamwork, drive escalation and issue resolution, and promote collaboration and coordination across stakeholders.
  • Collaborate with analytics, actuarial, and quality teams to develop, analyze, and distribute reports, and document program activities, interventions, and outcomes.
  • Perform in-depth analysis of high-cost claims, vendor-identified populations, and other defined groups, producing case studies, reports, and presentations.
  • Research and recommend interventions, identify and drive improvements, and take action to significantly impact healthcare costs.
  • Review high-cost claims and episodes of care to identify cost-saving opportunities, including site-of-care optimization, inappropriate utilization, payment integrity issues, contractual compliance, and coordination of benefits.
  • Analyze inpatient admissions, readmissions, specialty drug utilization, and high-cost professional and facility claims to identify healthcare trend drivers and develop targeted mitigation strategies.
  • Identify opportunities for site-of-service steerage, provider network optimization, out-of-network utilization management, care management interventions, and benefit design enhancements to reduce total cost of care.
  • Monitor emerging healthcare cost drivers, including specialty pharmaceuticals, oncology, behavioral health, specialist and emergency department utilization, and recommend interventions.
  • Measure and communicate intervention outcomes, including savings, quality impacts, operational effectiveness, and member experience considerations.
  • Partner with analytics teams to develop, analyze, and distribute reporting.
  • Liaise with analytics and cost-of-healthcare groups across the enterprise to compare trends, share knowledge, and measure outcomes.
  • Organize and lead cross-functional meetings and foster teamwork and collaborative problem-solving across stakeholders.
  • Facilitate cross-functional taskforces with specific cost-of-healthcare commitments.
  • Perform other duties as assigned.
Desired Qualifications
  • Familiarity with California healthcare data and the healthcare delivery system; health plan or provider experience is strongly desired.
  • Experience in healthcare cost analysis, population health outcomes, or program evaluation.
  • Expertise analyzing high-cost claims, episodes of care, and healthcare cost drivers to identify opportunities for medical cost reduction.
  • Ability to review complex claims for payment accuracy, contractual compliance, coordination of benefits, and potential payment integrity issues.
  • Knowledge of provider reimbursement methodologies, including DRG, case rate, per diem, percentage-of-charge, and letter-of-agreement arrangements.
  • Experience identifying fraud, waste, abuse, upcoding, unbundling, inappropriate billing, and other claim-payment vulnerabilities.
  • Experience performing root-cause analyses of trend drivers and developing business cases for cost-of-care interventions.

About the company

B

Blue Shield of California

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Blue Shield of California is a nonprofit health plan provider that offers medical insurance options for individuals, families, and employers within California. It operates as a mutual benefit corporation and maintains a broad network of healthcare professionals and facilities, enabling members to access care and manage claims through an online portal. Its services include preventive care programs and digital health coaching, with prior authorization required for certain medical, surgical, and some prescription drugs to control costs and ensure medical necessity. The company draws a substantial portion of its membership from CalPERS and focuses on delivering stable, affordable access to care within the state. Its goal is to provide members with reliable health coverage, a wide provider network, and tools to manage their health and expenses efficiently.

Company Size

5,001-10,000

Company Stage

N/A

Total Funding

N/A

Headquarters

null

Founded

1939

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Simplify Jobs

Simplify's Take

What believers are saying

  • September 2026 Virtual Blue expansion adds 260,000 members, boosting retention and employer appeal.
  • August 2026 Dignity, Providence, and Cedars-Sinai renewals protect network breadth across California.
  • Food as Health and fire-assistance programs strengthen brand trust while supporting Medi-Cal members.

What critics are saying

  • September 2026 ghost-network lawsuit survived dismissal; discovery threatens damages and reputational harm.
  • WARN filings in 2026 affected 205 workers, signaling ongoing restructuring and cost pressure.
  • California provider dependence on Cedars-Sinai, Providence, and Dignity Health creates contract-break existential risk.

What makes Blue Shield of California unique

  • Blue Shield of California combines nonprofit status with statewide California-only health plan distribution.
  • September 2026 Virtual Blue expansion reaches 410,000 members with $0 out-of-pocket virtual care.
  • September 2026 Food as Health invests $600,000 in nutrition-based chronic-care programs.

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Benefits

  • Mental Health Support

Company News

PR Newswire
Oct 26th, 2026
Blue Shield Promise invests $1M in new Southeastern San Diego urgent care centre

Blue Shield of California Promise Health Plan has made a $1 million community investment to support a new urgent care centre in Southeastern San Diego. San Ysidro Health opened the centre at the Joe & Vi Jacobs Center, with a ribbon-cutting held Friday. The 3,300-square-foot site offers an alternative to emergency rooms for the area's more than 153,000 residents. It provides after-hours care, laboratory and basic radiology services, and refers patients needing higher levels of care to nearby emergency rooms. Local residents have had limited urgent care options, said Kristen Cerf, president and chief executive officer of Blue Shield Promise. Many have turned to emergency rooms for non-emergency conditions. In July 2023, the health plan backed an urgent and cardiac care centre in El Cajon.

Black Radio Network
Oct 26th, 2026
Expanding Urgent Care in Southeastern San Diego.

Expanding Urgent Care in Southeastern San Diego. New San Ysidro Health Urgent Care Center will expand access to timely, high-quality care closer to home and work SAN DIEGO, Oct. 26, 2026 /PRNewswire/ - Blue Shield of California Promise Health Plan announced a $1 million community investment to support the new San Ysidro Health Southeastern San Diego (SESD) Urgent Care Center at the Joe & Vi Jacobs Center, expanding access to timely, convenient healthcare services for Southeastern San Diego residents. A ribbon-cutting event was held Friday to celebrate the center's grand opening and featured remarks from Assemblymember Dr. LaShae Sharp-Collins (D-San Diego), San Diego County Supervisor Monica Montgomery Steppe, and San Diego City Councilmember Henry L. Foster III. The investment reflects the organizations' shared commitment to improving community health by expanding access to after-hours, high-quality care close to home. "Access to timely care should not depend on where someone lives. For too many years, Southeastern San Diego residents have had limited urgent care options, leading many to seek treatment in emergency rooms for non-emergency conditions," said Kristen Cerf, president and CEO at Blue Shield Promise. "Our support for San Ysidro Health's new Southeastern San Diego urgent care center will help reduce barriers to treatment and connect families to the right care at the right time, close to where they live." The approximately 3,300-square-foot urgent care center, located within the Joe & Vi Jacobs Center, provides a community-based alternative to emergency room visits, operated by a trusted, local healthcare organization for Southeastern San Diego's more than 153,000 residents. In addition to treating immediate health needs, providers will connect patients to ongoing primary, preventive, and supportive care, including laboratory and basic radiology services, while referring patients who require higher levels of care to nearby emergency rooms. "This facility represents more than just access to medical services. It represents opportunity for so many people to not just survive, but to thrive here within San Diego," said Assemblymember Dr. Sharp-Collins. "For far too long, members of our community have gone without care they need because of barriers that never should have been put between them, meaning people and their health. Today this facility helps break down those barriers and brings hope closer to home." "We are deeply honored to partner with Blue Shield Promise to bring urgent care services to Southeastern San Diego," said Kevin Mattson, president and CEO of San Ysidro Health. "Our Southeast San Diego families no longer need to leave the community for vital, after-hours care. We are here for the working parent with the sick child, the concerned caregiver of a senior loved one and so many other visits outside of normal operating hours. Blue Shield Promise saw what we saw: a community deserving of the same access and opportunities for health as any other. Together, we are expanding much needed access to convenient, after-hours care for all." "For decades, San Ysidro Health has been a driving force in advancing community health across San Diego," Cerf said. "Its commitment to ensuring access to care for all mirrors our mission to improve health outcomes and reduce barriers. Together, we're helping strengthen the health and well-being of Southeastern San Diego for years to come." Today, Southeastern San Diego experiences a disproportionately high burden of chronic disease compared to other areas of the county. Social and economic challenges contribute to these health disparities, with 13% of residents living below the federal poverty level, 8% lacking health insurance, and 18% of households relying on SNAP/CalFresh benefits. These factors can increase health risks and make it more difficult for residents to prevent and manage chronic conditions. Expanding access to critical care in San Diego County has long been a priority for Blue Shield Promise. In July 2023, the health plan also supported the opening of Family Health Centers of San Diego's El Cajon Urgent and Cardiac Care Center through an investment to increase access to urgent and cardiac care services for East County San Diego residents. MEDIA CONTACTS: Alejandra Perez, San Ysidro Health, (619) 253-0140, [email protected] Juliane Matignas, Blue Shield of California, (310) 999-7890, [email protected] About Blue Shield of California Promise Health Plan Blue Shield of California Promise Health Plan is a managed care organization, wholly owned by Blue Shield of California, offering Medi-Cal. It is led by healthcare professionals with a "members-first" philosophy and committed to building a quality network of providers and partnering with community organizations for more than 500,000 Medi-Cal members across Los Angeles and San Diego counties. It was rated 4 out of 5 in NCQA's Medicaid Health Plan Ratings for 2025. For more information about Blue Shield of California Promise Health Plan, please visit www.blueshieldca.com/promise. For more news about Blue Shield of California Promise Health Plan, please visit promisenews.blueshieldca.com. Or follow Black Radio Network, Inc. on LinkedIn. About San Ysidro Health San Ysidro Health is a non-profit organization committed to providing high-quality, compassionate, accessible, and affordable healthcare services for the entire family. The organization was founded by seven mothers in search of medical services for their children in 1969. Over fifty-seven years later, San Ysidro Health now provides innovative health services to more than 162,000 lives in its care through a vast and integrated network of 50 program sites across San Diego County including medical clinics, dental clinics, behavioral health centers, HIV centers, WIC nutrition centers, mobile medical units, school-based health centers, chiropractic services, pediatric developmental clinic, teen clinic, senior health center and Program for All-Inclusive Care for the Elderly (PACE). For additional information, please visit San Ysidro Health at www.syhealth.org. SOURCE Blue Shield of California Promise Health Plan

Renascence
Oct 13th, 2026
Blue Shield of California named top insurer by Forrester for CX.

Blue Shield of California named top insurer by Forrester for CX. Blue Shield of California has been ranked among Forrester's top health insurers for brand and customer experience, standing out in a sector known for low member trust and engagement. What happened. Blue Shield of California has been named among Forrester's top-performing health insurers for brand and customer experience. The recognition comes from Forrester's benchmarking of how insurers are perceived and experienced by the people they serve, with Blue Shield of California highlighted as a standout performer in the health plan category. The health plan, which serves members across California, used the announcement to position its customer experience work as a differentiator in a sector where plan members often report low engagement and satisfaction with their insurers. Why it matters. Health insurance is routinely one of the lowest-scoring sectors in customer experience benchmarks, largely because interactions tend to be transactional, complex and triggered by moments of stress - a claim denial, a coverage question, a medical emergency. A health plan being singled out for strong brand and experience performance signals that meaningful differentiation is possible even in a category defined by regulatory complexity and low switching activity. For experience leaders, the takeaway is less about the insurance industry specifically and more about what independent, third-party recognition does for trust. In categories where customers have limited visibility into service quality before they need it, external validation from analysts like Forrester becomes a proxy signal that shapes employer purchasing decisions, broker recommendations and member retention - arguably more than marketing claims ever could. The renascence take. Rankings like this are easy to treat as a marketing win and move on. The more useful question for other operators is what specifically earns a health insurer this kind of recognition in a category where most interactions are adversarial by design - claims, denials, prior authorisations, billing disputes. In low-trust categories like health insurance, brand perception is built less by advertising and more by what happens in the worst moments - a denied claim handled with clarity, a complex authorisation process simplified, a call that resolves rather than escalates. The operators who earn these rankings are usually the ones who have redesigned their friction points, not their messaging. Any insurer - or any regulated, high-stakes service provider in MENA - serious about this kind of recognition should start by auditing its highest-anxiety member journeys, not its brand campaigns. This briefing was written by its Newsdesk, synthesising reporting from the outlets below. Follow the links for the original coverage. Questions Renascence get on this topic. Blue Shield of California was named among Forrester's top-performing health insurers for brand and customer experience, based on Forrester's benchmarking of how insurers are perceived and experienced by their members. More in Customer Experience Stay ahead of CX Get the signal, not the noise. The stories shaping customer experience - plus the Journal and Experience Loom - in your inbox.

Blue Shield of California
Oct 13th, 2026
Blue Shield of California Promise Health Plan earns 4 out of 5 stars in NCQA's 2026 Medicaid Health Plan Ratings for third consecutive year.

Blue Shield of California Promise Health Plan earns 4 out of 5 stars in NCQA's 2026 Medicaid Health Plan Ratings for third consecutive year. Top scores in preventive care, treatment outcomes, and population health reflect Blue Shield Promise's commitment to helping members access quality care and achieve better health outcomes. October 13, 2026 Blue Shield of California Promise Health Plan is celebrating another year of strong performance, earning 4 out of 5 stars in the 2026 National Committee for Quality Assurance's (NCQA) Medicaid Health Plan Ratings for the third consecutive year. Health plans are rated on a scale of 1 to 5 stars, with 5 stars representing the highest rating. The NCQA evaluates plans based on clinical quality and member experience using *HEDIS(R) and **CAHPS(R) data. Blue Shield Promise is one of only two Medi-Cal plans serving both Los Angeles and San Diego counties to receive a rating of 4 stars or higher in 2024, 2025, and 2026. "Blue Shield Promise's consistently strong ratings reflect the dedication of our care teams, provider partners, and community organizations to help members lead healthier lives," said Kristen Cerf, president and CEO of Blue Shield Promise. "Earning a 4-star NCQA rating for the third consecutive year demonstrates our commitment to preventive care, quality improvement, and equitable access to services. Through timely screenings, immunizations, proactive care management, and personalized support, we're helping members stay healthy and get the care they need." Strong performance in prevention and clinical quality Blue Shield Promise's highest scores were in two categories - treatment, and prevention and population health - emphasizing the health plan's commitment to helping members access quality care, manage chronic conditions, and get the services they need to improve their overall health and well-being. Blue Shield Promise earned the NCQA's highest rating of 5 out of 5 stars across four treatment measures: * Statin adherence for patients with cardiovascular disease * Statin adherence for patients with diabetes * Follow-up after emergency department visits for substance-use disorder * Plan all-cause readmissions These results reflect the health plan's focus on medication adherence, timely member follow-up after care transitions, and strong coordination among hospitals, provider groups, and internal care teams. Blue Shield Promise also earned the NCQA's highest rating of 5 out of 5 stars in three prevention and population health measures: * BMI percentile assessment * Description of membership (race, ethnicity, and language-preference collection) * Zoster immunizations for adults (herpes zoster/shingles vaccine) These results highlight the nonprofit health plan's efforts to better understand members' needs, advance health equity, and improve care across the diverse communities it serves. In addition, Blue Shield Promise received 4 out of 5 stars for prenatal, adolescent, and child immunizations, as well as breast cancer and cervical cancer screenings. These ratings reflect the health plan's commitment to bringing care directly to members where they live and work through well-child visits, mobile mammogram screenings, and immunization programs that help remove barriers to care for families. Blue Shield Promise also holds an NCQA Health Outcomes Accreditation, which recognizes organizations that use standardized data and measurement to identify their population's unique health needs and address differences in health outcomes, experience, and access to care. *HEDIS(R) Healthcare Effectiveness Data and Information Set **CAHPS(R) Consumer Assessment of Healthcare Providers and Systems

Blue Shield of California
Oct 12th, 2026
Blue Shield of California ranked among Forrester's top health insurers for brand and Customer Experience.

Blue Shield of California ranked among Forrester's top health insurers for brand and Customer Experience. Nonprofit health plan ranked No. 3 nationally for Total Experience among health insurers. October 12, 2026 As Californians prepare for open enrollment this fall, choosing a health plan is about more than coverage. People evaluate health plans not only by their benefits, but also by what the organization stands for, the commitments it makes, and the experiences it delivers, from accessing care to finding information and getting support when it's needed. Blue Shield of California's work to align its brand promise with the experiences it delivers is reflected in Forrester's U.S. Health Insurers Total Experience Score Rankings for 2026, where Blue Shield ranked No. 3 among 16 health insurers nationwide and was recognized as a Strong Performer. Blue Shield's score also increased 7.1 points from 55.9 in 2025 to 63.0 in 2026, five points above the industry average, remaining in Forrester's Leading Quadrant of the growth grid for U.S. health insurers. Blue Shield believes this recognition underscores its progress in building trust through both its brand promise and member experience. "We're focused on making healthcare simpler and more responsive to the needs of the people we serve," said Ellen Sexton, executive vice president and chief growth officer at Blue Shield of California. "For us, this recognition reflects exciting progress, but more importantly it reinforces our commitment to listening to our members, earning their trust, and continuously improving the experiences they have every day." Blue Shield's 2026 results Blue Shield believes its performance reflects strong momentum across key measures: * No. 3 among 16 U.S. health insurers evaluated * Score of 63.0, up 7.1 points from 2025 * Five points above the healthcare industry average * Recognized as a Strong Performer * Positioned in Forrester's Leading Quadrant of the growth grid for U.S. health insurers For Blue Shield, the findings reflect continued progress in its efforts to simplify healthcare, strengthen support, and deliver greater value for members and the broader marketplace. What is Total Experience? Forrester has measured Customer Experience in the health insurance industry since 2016. In 2025, it expanded its methodology to include Brand Experience, creating a new Total Experience score that evaluates how well an organization's reputation and promises align with the experiences it delivers. The approach emphasizes brand trust, recognizing that trust is built through every interaction and every impression. When expectations and experiences align, organizations are better positioned to build lasting relationships with the people they serve. In healthcare, that connection is especially important. Choosing coverage, understanding benefits, comparing options, and accessing care can be challenging. Health plans that provide clear information, meaningful support, affordability, and easier navigation can help people make more confident decisions about their healthcare and well-being. Making healthcare easier A strong brand is ultimately defined by the experience it delivers. For Blue Shield, that means bringing its mission of healthcare worthy of family and friends to life through innovative products, personalized support, and resources designed to help members navigate care more easily. Investments in digital tools, service models, transparency, and affordability are aimed at reducing complexity and helping people make more informed healthcare decisions. Together, these efforts strengthen the connection between what Blue Shield promises and what members experience. For consumers evaluating health plans during open enrollment, that connection matters. Choosing a health plan is one of the most important healthcare decisions people make each year, and today's consumers expect both quality coverage and a seamless, trustworthy experience. Building trust beyond the member experience Forrester's Brand Experience measure also captures perceptions among people who are familiar with a company but are not current customers. Blue Shield believes its recognition in the Leading Quadrant of the growth grid for U.S. health insurers aligns with its values and trust, and indicates that the brand is resonating beyond its existing member base. The recognition comes as Blue Shield continues to strengthen the experience it delivers across every touchpoint. That focus is also reflected in the company's new "This Is Your Shield" campaign, which positions Blue Shield as a trusted partner helping people navigate healthcare with confidence. "Creating a simpler, more supportive healthcare journey for our members is at the heart of everything we do," said Jigar Shah, chief marketing and strategy officer at Blue Shield of California. "It is an honor to be recognized among leaders in experience, and we know that we're not done yet. We will continue investing in the programs and tools that help us better serve our members and communities." Forrester does not endorse any company, product, brand, or service included in its research publications and does not advise any person to select the products or services of any company or brand based on the ratings included in such publications. Information is based on the best available resources. Opinions reflect judgment at the time and are subject to change. This report is part of a broader collection of Forrester resources, including interactive models, frameworks, tools, data, and access to analyst guidance. For more information, read about Forrester's objectivity here.