Utilization Management Sr Mgr - ReqCode 574BR

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.

The Sr. Manager, Utilization Management is responsible for strategic planning to achieve Medical Management/HCS business results. The Sr. Manager ensures coordination and integration of the function with other BSC business units. This position will establish benchmarks, targets, operational best practices, and performance metrics, and build core competencies related to utilization and medical cost management. The Sr. Manager will also be accountable for leadership and development of the Utilization Management team.

Responsibilities :

Develops and aligns operational and performance goals for overall Medical Management department, and establishes consistent processes to track and measure goals, outcomes, and process improvement

Evaluates the effectiveness of Bed Day strategy: tools and system used, the implementation of new tools and the development of effective data reports to pro-actively manage medical cost
Develops and maintains strategic relationships across business units; and deals with significant issues across business units as it relates to shared goals and outcomes.

Responsible for planning and management of overall labor and expense budget and working alongside Finance department to meet departmental budget goals
Evaluation and process improvement for the reduction of inappropriate admits, re-admits, and designing discharge planning that is new and competitive
Effectively utilizes data to build the UM program and capabilities and to plan and implement succession
Coaches, develops and mentors leadership team through effective communication and identifying development opportunities

Provides leadership to staff by strengthening productivity and development through process management and workflow redesign, and identifying opportunities for development

May be the driver or lead special projects/committees/task forces.

Oversight of Performance Improvement Plans

Qualifications:

Current CA RN License required. Bachelor' s of Science in Nursing required, advanced degree preferred.

At least three years experience in leading and managing teams required with demonstrated success in defining performance objectives and developing and mentoring staff required

Five to seven years clinical acute care experience in utilization management and case management required

Three to five years managed care experience in medical management for UM/CM

Strong understanding of NCQA, URAC, federal and state regulatory requirements. Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable

Solid case preparation and abstracting skills with strong verbal and written communication skills

Comprehensive knowledge of case management, discharge planning, utilization management and community resources

Demonstrates excellent leadership, communication and negotiation skills with the ability to interact and influence all levels of the organization including executive management and key decision-makers

Strong ability to analyze the root-cause of problems and recommend and implement thoughtful, efficient, and successful solutions

Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care

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

Blue Shield of California is an Equal Opportunity Employer