Your Role
The UM Prior Authorization teamconducts medical necessity reviews for services before they are rendered. TheSr. Manager Medical and Utilization Reviewwill report to theDirector Medical and Utilization Review. In this role you will bemanaging a high functioning team, have direct oversight of day-to-day operations and participate in process improvement/cost of health care initiates.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,buildingand 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 and methods in collaboration with Director.
- Participate in the development and implementation of the annual budget under the direction of Director.
- Ensureworkflowprocedures and guidelines are clearly documented and communicated.
- Interpret or initiate changes in guidelines/policies/procedures.
- May lead special projects/committees/task forces.
- Manages a team and/or department with focus on policy and strategy implementation.
- Establishes operational plans with measurable contribution towards the achievement of results for the function.
- Provides measurable input to new products, processes or standards in operational plans that will have some impact on the achievement of overall function results.
- Exerts significant decision-making authority, guided by resource availability and functional objectives.
- Has budgetary responsibility and/or manages certain processes or projects within department’s budget.
- Responsible for making moderate to significant improvements of processes and policies to enhance performance of the department.
- Requires ability to exert influence on others within department in the development of multiple objectives and annual goals for a department.
- Influences higher-level management on large-scale tactical changes and organization improvements.
- Manages a large team consisting of experienced clinical professionals. Leads, directs and reviews the work of team who exercise latitude and independence in their assignments.
- Manage multiple regulatory reports.
- Manage operational and regulatory reports.
- Ensure compliance to regulatory and accreditation standards.
- Collaborate across functionally to improve member outcomes
Your Knowledge and Experience
- Requires a bachelor's degree or equivalent experience
- Requires a current California RN License
- Requires at least 10 years of prior relevant experience including 4 years of management experience
- Requires knowledge of regulatory requirements for all Lines of Business (Medi-Cal, ASO/SA, IFP, Medicare Advantage)
- Requires practical knowledge in leading and managing the execution of processes, projects and tactics within an area
- Requires strong emotional intelligence
- Requires the ability to work collaborative with cross functional operations
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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