Clinical Programs Specialist

Position Summary

The Clinical Programs Specialist provides operational and administrative support for the day-to-day management of clinical programs and clinical vendor partnerships under the direction of the Clinical Programs Specialists Manager. This role coordinates program reporting, vendor invoices, and drug list maintenance. This role also maintains program workflows and documentation, supports program implementations, monitors recurring deliverables, supports stakeholder communications, and tracks issues through resolution. The Specialist helps ensure established program processes are executed consistently, accurately, and in accordance with contractual, regulatory, and organizational requirements. This role helps ensure programs are executed effectively and efficiently; stakeholders remain informed, and both clients and members receive timely, high-quality support involving clinical programs involving clinical vendor partners.

Position Responsibilities:

Vendor Clinical Program Administration

• Supports administration and operational activities for assigned clinical programs involving clinical vendor partners.
• Supports the maintenance of program workflows, standard operating procedures, job aids, process maps, reference materials, and other operational documentation.
• Monitor shared inboxes, work queues, pending activities, recurring deliverables, and escalations to support timely follow-up and continuity of program operations.
• Document vendor program activities, decisions, issues, interventions, and follow-up actions in applicable systems and tracking tools.

Program Coordination & Workflow Management

• Apply established workflows and assist with updates when processes, systems, client requirements, or regulatory guidance change.
• Identify and support resolution of workflow gaps, document operational risks, and escalate recommendations to the Clinical Partnerships Lead.
• Balance multiple work-streams, prioritize time-sensitive activities, and meet established deadlines with minimal oversight.
• Maintain clinical program resources, including drug lists, through routine reviews, scheduled updates, and ad hoc changes.

Clinical Vendor & Stakeholder Support

• Support the monitoring of vendor service-level commitments, reporting schedules, and required deliverables; escalate delays or performance concerns.
• Coordinate resolution of program inquiries and escalations while promoting a positive stakeholder and member experience.
• Support operations including vendor invoicing and reporting, custom client implementation requests, reporting requirements, claims monitoring, issue resolution, member communication proofs, and ongoing vendor program maintenance.
• Collaborate with internal and external stakeholders to ensure effective communication, coordination, a satisfactory client experience, and continuity of member care.
• Support the Clinical Programs Business Development needs, including client contracting, vendor management, preparation of opportunity analyses, and program sales support.

Quality, Compliance & Operational Excellence

• Maintain compliance with all applicable federal, state, local, and organizational regulations, policies, and guidelines.
• Adhere to HIPAA requirements, internal SOPs, and company policies in the performance of daily responsibilities.
• Remain current on organizational communications, clinical updates, and process changes and apply them appropriately to daily work activities.
• Uphold general business needs and operations as required 

Required Qualifications:

• Active, unrestricted pharmacy technician license, licensed practical nurse (LPN), certified medical assistant (CMA), or equivalent license in healthcare administration, public health, or health sciences.
• 1+ years of applicable experience in a health plan, managed care organization, PBM, TPA, case management, utilization management, quality, population health, clinical operations, or related healthcare environment.
• Experience supporting established clinical program processes, operational workflows, implementations, or stakeholder coordination.
• Ability to balance multiple complex projects simultaneously with minimal direction
• Strong oral, written, interpersonal, problem-solving, facilitation, and organizational skills.
• Have a designated workspace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations
• Have required internet connectivity consistent with company remote-work standards.

Preferred Qualifications:

• Experience supporting clinical vendors, maintaining service-level or performance tracking, and supporting project implementations.
• Experience working within a Medicare Advantage, Medicaid, Commercial health plan, managed care organization, TPA, PBM, or value-based care environment.
• Knowledge of HEDIS, Medicare Stars, CAHPS, CMS requirements, NCQA standards, or other health plan quality programs.
• Experience administering or coordinating clinical, quality, care management, case management, utilization management, and/or population health program processes
• Experience in business analysis and project management.
• Experience working with medical and pharmacy claims
• Experience with Confluence, Jira, Tableau, Salesforce
• Highly detail-oriented and analytical; bilingual Spanish preferred