Clinical Nurse Educator, Consultant (Utilization Management)

at  Blue Shield of California

YOUR WORK

In this role, you will:

• Manage and facilitate clinical education for new hires and existing clinical staff
• Support Utilization Management with a focus on new hire training and continuing education for Blue Shield of California clinicians working concurrent review and prior authorizations
• Conduct training classes in a virtual learning environment and at times in person
• Act as a liaison and provide training support and clinical education to clinicians
• Report any instances of noncompliance, such as access issues or quality concerns, to the appropriate department along with recommended corrective actions
• Partner will quality team and compliance to address quality trends or compliance issues that require training or education with a focus on DHCS, NCQA, and DMHC regulatory compliance
• Act as a Utilization Management clinical subject matter expert for Enterprise Learning guiding principles and processes
• Provide learning support and create Behavioral Health clinical learning scenarios
• Be a subject matter expert in MCG clinical criteria and BSC medical policies
• Clinical education on Utilization Management including concurrent reviews and prior authorizations
• Utilization Management concurrent review and prior authorization department processes and workflows
• Develop and design training modules for Utilization Management for all lines of business
• Create learning competencies checklists, mock case scenarios, and assessments as needed for Utilization Management reviews using MCG clinical guidelines and medical policies
• Support clinical learning projects and process improvements for Utilization Management (Concurrent Review and Prior Authorizations)

QUALIFICATIONSYOUR KNOWLEDGE AND EXPERIENCE

• Requires a bachelor’s degree or equivalent experience
• Requires a current California RN license
• Requires at least 7 years of prior relevant experience
• Experience working in Utilization Management, preferred
• Experience in Health Insurance, preferred
• Knowledge of learning principles and models, preferred
• Experience facilitating presentations using virtual technology, preferred

PHYSICAL REQUIREMENTS:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

JOB DESCRIPTIONYOUR ROLE

The Medical Care Solutions education team is responsible for all clinical education for all departments within Medical Care Solutions as well as some Health Solutions teams. This includes Utilization Management, Care Management, Post Service, and Appeals. This clinical educator role will be responsible for Utilization Management for all lines of business. The Clinical Educator position will report to the Senior Stakeholder Manager in Enterprise Learning supporting Health Solutions.

In this role, you will:

• Manage and facilitate clinical education for new hires and existing clinical staff
• Support Utilization Management with a focus on new hire training and continuing education for Blue Shield of California clinicians working concurrent review and prior authorizations
• Conduct training classes in a virtual learning environment and at times in person
• Act as a liaison and provide training support and clinical education to clinicians
• Report any instances of noncompliance, such as access issues or quality concerns, to the appropriate department along with recommended corrective actions
• Partner will quality team and compliance to address quality trends or compliance issues that require training or education with a focus on DHCS, NCQA, and DMHC regulatory compliance
• Act as a Utilization Management clinical subject matter expert for Enterprise Learning guiding principles and processes
• Provide learning support and create Behavioral Health clinical learning scenarios
• Be a subject matter expert in MCG clinical criteria and BSC medical policies
• Clinical education on Utilization Management including concurrent reviews and prior authorizations
• Utilization Management concurrent review and prior authorization department processes and workflows
• Develop and design training modules for Utilization Management for all lines of business
• Create learning competencies checklists, mock case scenarios, and assessments as needed for Utilization Management reviews using MCG clinical guidelines and medical policies
• Support clinical learning projects and process improvements for Utilization Management (Concurrent Review and Prior Authorizations