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Manager, Program Management Clinical

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  • Job
    Full-time
    Senior & Expert Level
  • Business, Operations & Strategy
  • $109.1K - $163.7K
  • Long Beach, +2

Requirements

  • 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
  • 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

Responsibilities

  • 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

FAQs

What is the main responsibility of the Manager of Quality Review in this role?

The main responsibility of the Manager of Quality Review is to lead the team in quality initiatives, provide and present data to business unit leaders, and work closely with the Senior Manager on internal process improvement.

Who does the Manager of Quality Review report to?

The Manager of Quality Review will report to the Senior Manager of the Quality & Communications team.

What qualities are you looking for in a candidate for this position?

We are looking for candidates who are energized by creative and critical thinking, able to build and sustain high-performing teams, can get results the right way, and foster continuous learning. Leadership skills are also essential for this role.

What is the focus of the Quality Review team's internal audits?

The Quality Review team focuses on completing internal audits of front-line staff and vendors to ensure alignment with department processes and regulatory compliance. They also provide coaching and work closely with business leaders to drive optimal results.

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Finance
Industry
5001-10,000
Employees
1939
Founded Year

Mission & Purpose

Blue Shield of California strives to create a healthcare system worthy of its family and friends that is sustainably affordable. Blue Shield of California is a tax-paying, nonprofit, independent member of the Blue Shield Association with 4.7 million members, 7,800 employees, and $22.9 billion in annual revenue. Founded in 1939 in San Francisco and now headquartered in Oakland, Blue Shield of California and its affiliates provide health, dental, vision, Medicaid and Medicare healthcare service plans in California. Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.