Manager, Program Management Clinical

Job Description

Your Role

The Quality Review team completes internal audits of front-line staff and vendors to ensure alignment with department processes and regulatory compliance. Quality Reviewers also provide coaching and work closely with business leaders to drive optimal results. The Manager of Quality Review will report to the Senior Manager of the Quality & Communications team. In this role you will be responsible for leading the team in numerous quality initiatives, providing and presenting data to business unit leaders, and working closely with the Senior Manager on internal process improvement. 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:

• Be a people leader responsible for leading a small team of clinical and non-clinical Quality Reviewers, manage day-to-day operations and provide staff support
• Monitor the regulatory compliance and quality of service provided to members through internal case review
• Monitor the execution of internal processes and procedures as requested by business unit leaders; ensure compliance with regulatory, legal, and contractual requirements, as well as accreditation and Blue Shield standards
• Communicate with internal and external leaders to ensure audit tools meet all regulatory and process expectations
• Coordinate all information, provide data analysis and respond to the appropriate parties; participate and present in committee meetings
• Be responsible for strategic alignment and integration across projects/programs in support of business unit process and administrative efficiency
• Be responsible for medium complexity projects/programs, manage them from initiation through delivery and monitor for continuous improvement
• Exercise independent judgement in developing methods, techniques and evaluation criterion for obtaining results
  
  

Qualifications

Your Knowledge and Experience

• Requires a bachelor’s degree or equivalent experience
• Requires at least 7 years prior relevant experience, including 3 years of management experience gained as a team leader, supervisor or project/program manager
• Requires current California RN license OR Master’s Level Licensed Mental Health individual (LMFT/LCSW) & 4+ years related experience and/or training, or equivalent combination preferred
• Requires Care/Case Management and/or Utilization Management experience, with knowledge of medical necessity criteria and applying LOCUS/CALOCUS/ECSII/ASAM guidelines
• Requires familiarity with regulatory requirements and accreditation standards for Utilization Management and Care/Case Management
• Managed Care experience strongly preferred
  
  

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.

About The Team

Blue 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.