Utilization Management Manager - ReqCode 1052BR

Helping make high-quality health care for Californians easy, accessible and affordable is a great calling. Knowing that your company has contributed over $125 million back into California communities and will continue to do so is flat out uplifting. Join the hardest working, not-for-profit health plan in California and be part of the solution.

Working with complex cases promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits. Works with other members of HCS team, provider, hospitals, IPA/MGs, members and their families to plan and review medical necessity, intensity of services, level of care, length of stay and general appropriateness of care. Provides guidance to the provider network. Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care. May provide case management to member segments with chronic or catastrophic illness. Specific licensing requirements may apply depending upon position i.e. LVN or RN.

Responsibilities:

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 and methods

Participates in the development and implementation of the annual budget

Ensures work flow procedures and guidelines are clearly documented and communicated

Interprets or may initiate changes in guidelines/policies/procedures

May lead special projects/committees/task forces

Directs the activities of one or more smaller/less complex department(s) or functional area(s) through subordinate supervisors/team leads

Has full management responsibility for staff (i.e. salary actions, promotions, performance reviews, and disciplinary matters) in accordance with the organization's policies and applicable laws

Monitors on-going performance and communicates expectations and results

Identifies staffing needs and objectives and provides developmental and training opportunities for team members

Skills and Experience Requirements:

Current active unrestricted CA RN License

Bachelor of Science in Nursing or advanced degree in Nursing preferred

Five years acute care experience preferred

2+ years nursing experience in utilization management preferred

Experience leading and managing clinical staff

Demonstrated ability to independently assess, evaluate, and interpret clinical information

Extensive knowledge of evidenced based clinical practice guidelines

Strong clinical documentation skills, independent problem identification and resolution skills

Working knowledge of regulatory and accreditation standards preferred such as URAC, NCQA, DMHC, Case Management Society of America (CMSA)

Knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act - HIPAA)

Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets preferred

Superior interpersonal skills; effective verbal and written communication and negotiation skills

Able to work effectively in a team environment

Strong organizational and time management skills; ability to manage multiple priorities

Ability to work on projects with moderate supervision

Possesses cultural awareness to work effectively, respectfully, and sensitively within the client's cultural context

Able to operate PC-based software programs including proficiency in Word and Excel

Blue Shield of California is an Equal Opportunity Employer.