Manager, Utilization and Medical Review

at  Blue Shield of California

YOUR WORK

In this role, you will:

• Establish operational objectives for department and/or functional areas and participate with managers and stakeholders to establish shared objectives
• Be responsible for functional area quality and compliance results. Prepare files for regulatory and internal audits. Participate in regulatory and internal audits when necessary
• Adhere to the team’s annual budget and participate in budget planning under the direction of the team’s Manager and Director
• Ensure all work-flow procedures and guidelines are clearly documented, updated, and communicated timely to the team
• Interpret or initiate changes in guidelines/policies/procedures
• Develop and implement recommendations for improvement of quality and production
• Stay current on regulatory changes and industry requirements
• Responsible for reporting, analysis, and vendor oversight metrics
• Collaborate with internal business partners

QUALIFICATIONSYOUR KNOWLEDGE AND EXPERIENCE

• B achelors of Science in Nursing or advanced degree preferred.
• Requires a current CA RN license
• Requires at least 7 years of prior relevant experience including 3 years of management experience gained as a team leader, supervisor, or project/program manager
• Has functional expertise within the area of responsibility
• Medi-Care, Medi-Cal, and Commercial experience preferred
• Experience with data analysis, trending, and inventory management preferred
• Regulatory audit experience with file preps, presentation, and CAP resolution preferred
• Understands basic management approaches such as work scheduling, prioritizing, coaching, and process execution, work organization, risk management, and delegation

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 Post Service Clinical Review team is hiring an RN manager who will be responsible for leading the clinical team that reviews post service and provider appeal cases for Commercial, MediCare, and MediCal lines of business.. The RN manager will report to the Sr. RN Manager. In this role you will be responsible for inventory management, staffing, vendor oversight, transformation readiness, audit readiness, reporting, special projects, and compliance. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

In this role, you will:

• Establish operational objectives for department and/or functional areas and participate with managers and stakeholders to establish shared objectives
• Be responsible for functional area quality and compliance results. Prepare files for regulatory and internal audits. Participate in regulatory and internal audits when necessary
• Adhere to the team’s annual budget and participate in budget planning under the direction of the team’s Manager and Director
• Ensure all work-flow procedures and guidelines are clearly documented, updated, and communicated timely to the team
• Interpret or initiate changes in guidelines/policies/procedures
• Develop and implement recommendations for improvement of quality and production
• Stay current on regulatory changes and industry requirements
• Responsible for reporting, analysis, and vendor oversight metrics
• Collaborate with internal business partner