Manager Utilization Management, Blue Shield of California, Rancho Cordova, CA
Posted on November 4th, 2016
Manager Utilization Management
There's never been a better time to join Blue Shield!
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. Blue Shield of California 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 $325 million to the Blue Shield of California 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.
Job Details
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.
Job Required Education/Experience
Supervisory Responsibilities Generally requires Bachelor's degree or equivalent work experience and thorough experience in Nursing, Health Care Administration or related field. Directs and controls the activities of one or more smaller/less complex department(s) or functional area(s) through subordinate supervisors/team leads. May manage staff directly or have managerial responsibility for a functional area without subordinate employees. 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. Provides developmental and training opportunities for team members. Identifies staffing needs and objectives.
Job Additional Education/Experience
Strong working knowledge of managed care operations, comfortable managing commercial, PPO populations, positive relationship and interactions with IPA's Medical Groups, Hospitals. Strong clinical judgement and experience with Medicare and Behavioral Health.
Working knowledge of MCG, Milliman Care Guidelines, Interqual guidelines.
For immediate consideration, please apply at: https://sjobs.brassring.com/TGnewUI/Search/Home/Home?partnerid=25386&siteid=5192