Your Role
Blue Shield of California is looking for a clinical leader to oversee the behavioral health utilization management for all product lines. Reporting to the Sr. Director, Behavioral Health Clinical Operations, the role of the Director, Behavioral Health Utilization Management is critical to the success of Blue Shield of California and the Utilization Management department in realizing its goals and objectives. This individual will play a key role as part of Utilization Management team in delivering and collaborating on all aspects of utilization management and care coordination for behavioral health membership for all lines of business. This leader will also provide direction and leadership in compliance to regulatory requirements and key operational metrics.
Your Work
In this role, you will:
- Manage and monitor prior authorization, concurrent review, and transitions of care/continuity of care to ensure that the patient is getting the right care in a timely and cost-effective way.
- Lead development of Behavioral Health UM strategy by leveraging the use of data/analytics to inform and influence technology solutions to streamline operational efficiencies. Build a cost-benefit methodology to rationalize decisions on UM reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.
- Provide analysis and reports of significant utilization trends, patterns, and resource allocation. Partner with physicians and BH clinicians to develop improved utilization of effective and appropriate services.
- Establish and measures productivity metrics in order to support workforce planning methodology and rationalization of services required to perform UM reviews and adapt to membership growth.
- Ensure alignment of the authorization strategy with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.
- Manage strategic projects and supporting operations initiatives.
- Lead operational implementation of transformation changes (organizational management, process implementation, technology adoption).
- Responsible for utilization management teams' performance, resource management, continuous improvement, and training.
- Responsible for operational audit readiness, ensuring adequate processes and internal audit measures in place and maintained quarterly.
- Ensure all operational processes are meeting regulatory and accreditation requirements
- Ensure front line staff are receiving weekly to monthly one on one coaching celebrating successes and discussing opportunities for improvement.
- Fosters a culture of process excellence, BSC leadership principles, and a great place to work environment
Your Knowledge and Experience
- Current CA RN License, LCSW, LMFT, LPCC, or PsyD by the Board of Behavioral Health Sciences.
- Requires a college degree or equivalent experience and minimum of 10 years prior relevant experience, including 6 years of management experience.
- Certified Case Manager (CCM) or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field.
- Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, CMS, DHCS)
- Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable
- Requires broad management knowledge to lead project teams in one department/function or large centralized function.
- Master’s Degree in a healthcare field preferred