Job DescriptionYour RoleThe Behavioral Health Utilization Management team performs prospective, concurrent, retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business. The Senior Manager Utilization Management -Behavioral Health will report to the Director of Behavioral Health Utilization Management and Care Management.
Your WorkIn this role, you will:
- Manage all aspects of day-to-day operations of the Behavioral Health UM program, including adherence to regulatory compliance and direct oversight of performance quality.
- Assure compliance with appropriate regulations and oversee and assure that there are comprehensive quality processes and utilization management programs in place.
- Responsible for the fiscal management of the program, including implementing and managing the budget.
- Directs and oversees support, management, and mitigation of issues related to non-quantitative treatment limitations and support regulatory compliance.
- Manages all aspects of MHPAEA requirements, implementation, create, and maintain supporting documentation, manage audits and information related to MHPAEA compliance.
- Establish and manage workflows, project, and communication plans to support the development and maintenance of a program to assure compliance with MHPAEA, including State regulations.
- May manage large projects or processes that span outside of immediate job area.
- Manages all strategic planning activities of the Program with the primary goal of ensuring the ongoing effectiveness of the Program.
- Establishes staffing requirements, directs recruitment, selection and when necessary disciplinary action within the Program.
- Manages the Program within allocated budgetary parameters and collaborates in the development of the fiscal budget.
- Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
QualificationsYour Knowledge and Experience - Current CA RN license. Bachelors of Science in Nursing or advanced degree preferred.
- Requires at least 10 years of prior relevant experience
- Requires 4 years of management experience which includes the supervision of clinical and professional staff, budgeting, program planning
- Three (3) years conducting Utilization Management for a health insurance plan or managed care environment preferred
- Strong understanding of behavioral health utilization management including application of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
- Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databases
- Basic familiarity with accreditation bodies
- Successful track record in building and maintaining positive cross-functional relationships
- Aptitude for developing a quick understanding of people, processes, and technology
- Excellent analytical, communication skills, written skills, time management, and organizational skills
- Possess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiative
- Ability to identify problems and works towards problem resolution independently, seeking guidance as needed
Pay Range: The pay range for this role is: $ 136400.00 to $ 204600.00 for California.
Note:Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
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About the TeamBlue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values: - Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
- Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model:Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.
Two ways of working: Hybrid (our default) and office
- Hybrid - In a business unit approved office a few times per year to 3 days per week, on average
- Office - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an "Essential Role," the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. 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.
Equal Employment Opportunity: 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.