Manager, Utilization and Medical Review','180020R','Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. **MEMBERS ONLY**SIGN UP NOW***. is focused on transforming health care by making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 3.5 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than million to the **MEMBERS ONLY**SIGN UP NOW***. Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution. We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.','!*!Utilization and Medical Review: Ensures accurate and timely prior authorization of designated healthcare services, continuity and access to care approvals and retrospective clinical review activity.
Utilization & Medical Review Management:
Oversees and directs the development, evaluation and implementation of new or changing health care programs and clinical review of medical services for the organization using the established and approved Blue Shield Medical Policies which align with nationally recognized standards.
Responsible for program execution and drives medical program management for specific clinical programs.
Responsible for inventory management, monitors team performance ensuring service level agreements with internal business partners as well as external regulatory turnaround times are met.
Establishes operational objectives for department or functional area and participates with other managers to establish group objectives.
Responsible for team, department or functional area results in terms of planning, cost in collaboration with Senior Manager.
Participates in the development and implementation of the annual budget under the direction of Senior Manager / Director.
Ensures work flow procedures and guidelines are clearly documented, communicated.
Interprets or may initiate changes in guidelines/policies/procedures.
Responsible for developing and communicating established individual and team performance metrics
Responsible for staff development, career planning, coaching and formal performance management
May lead special projects/committees/task forces.
Other duties as assigned.','!*!
Current CA RN License.
Bachelors of Science in Nursing or advanced degree preferred.
Understands basic management approaches such as work scheduling, prioritizing, coaching and process execution, work organization, risk management and delegation.
Understands Blue Shield of CA's mission and business plan.
Has functional expertise within the area of responsibility.
Typically, requires advanced knowledge of job area usually obtained through advanced education combined with experience.
Typically, requires a college degree or equivalent experience and minimum 7 years prior relevant experience, including 3 years of management experience gained as a team leader, supervisor or project/program manager.
3 years of Claims Operations experience preferred with an insurance carrier or medical group.','!*!Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork – Activity level: Sedentary, frequency most of work day.Please click here for further physical requirement detail. ','!*!Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork – Activity level: Sedentary, frequency most of work day.Please click here for further physical requirement detail. ','','Clinical Management','United States of America-California-Rancho Cordova','','Health Care Quality & Affordability','Full-time','Aug 10, 2018','External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.','Manager, Utilization and Medical Review