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.
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