Your Role

The Utilization Management Prior Authorization team ensures accurate and timely prior authorization of designated healthcare services, continuity or care, and access to care clinical review determinations. The Manager, Utilization and Medical Review will report to the Sr. Manager, Utilization and Medical Review. In this role you will be managing a high functioning team, have direct oversight of day-to-day operations and participate in process improvement/cost of health care initiatives. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building, and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Establish operational objectives for department or functional area and participate with other managers to establish group objectives 
• Be responsible for team, department, or functional area results in terms of planning, cost in collaboration with Sr Manager 
• Participate in the development and implementation of the annual budget under the direction of Sr Manager / Director 
• Ensure workflow procedures and guidelines are clearly documented and communicated 
• Interpret or initiate changes in guidelines/policies/procedures 
• Manage multiple regulatory reports
• Establish and manage operational reports
• Ensure regulatory and accreditation standards are met for multiple lines of business
• Collaborate across functionally to improve member outcomes
• Participate in Regulatory and Internal Audits.

Your Knowledge and Experience

• Requires a bachelor's Degree or equivalent experience 
• Requires a current California RN License 
• Requires at least 7 years of prior relevant experience including 3 years of management experience
• Has demonstrated experience with basic management approaches such as work scheduling, prioritizing, coaching, process execution, work organization, inventory management, risk management and delegation
• Knowledge of regulatory requirements for all Lines of Business (Medi-Cal, ASO/SA, IFP, Medicare Advantage) preferred
• Requires strong emotional intelligence skills
• Requires the ability to work collaborative with cross functional operations

Pay Range:

The pay range for this role is: $ 109120.00 to $ 163680.00 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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