Your Role The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Senior Medical Director FEP Prior Authorization and Post Review will report to the Vice President, Medical Management or their designee. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for Federal Employee Program (FEP) membership. These functions include performance of pre-service and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews. The Senior Medical Director for FEP Prior Authorization and Post Review facilitates performance management and goals in alignment with organizational goals for the FEP membership. Moreover, this role leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California FEP members. You will also provide direction and leadership in compliance to regulatory requirements and key operational metrics and work collaboratively with the VP of Medical Management and Medical Directors in Utilization Management to achieve these goals.Your Work In this role, you will: Complete assigned clinical reviews (IP Admission and Concurrent, Lower Level of Care, Preservice requests, Post-service medical claim review, Provider Claims Disputes, Medical pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for FEP membershipProvides clinical leadership and HR oversight for FEP Medical Director teamPartner closely with the VP Medical Management and Medical Directors in Utilization Management to develop improved utilization of effective and appropriate services, and support operational implementation of transformation initiatives for the FEP membershipSupport VP, Medical Management and Medical Directors in Utilization Management in coordinating the care of FEP membership to provide access to high-quality health care to these membersServe as a clinical, regulatory and quality improvement resource and clinical thought leader within the organizationSupport Vice President, Medical Management in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driverCollaborate with teams in the implementation and operation of assigned initiativesUnderstands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance ProgramAttends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct classParticipates in assigned CommitteesAbides by all applicable laws and regulations as mandated by state and federal lawAny other assigned dutiesYour Knowledge and Experience A Medical degree (M.D./D.O.) Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)Maintain active, unrestricted California State Medical License requiredMaintain Board Certification in one of ABMS categories required (preferably Internal Medicine)Minimum of 2 years of previous medical leadership experienceMinimum 5 years direct patient care experience post residency in: Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (e.g. Psychiatry, Geriatrics, OBGYN), Adult based care, Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (with 5+ years of inpatient experience), Psychiatry, Geriatrics, OBGYNDemonstrated proficiency in at least 3 of the following: MEDICARE/MEDICARE STARS, NCQA/URAC/Quality Programs, Policies/Procedure, Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population HealthKnowledge and skilled application of national evidence-based medical necessity criteria references (MCG or InterQual)An ability to work independently to achieve objectives and resolve issues in ambiguous circumstancesClear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communicationsStrong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and moreExcellent written and verbal communication skillsExcellent analytical, time management and organizational skillsProficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

Radiology Technologist - CT Scan TechWe are seeking a skilled Radiology Technologist specializing in CT Scans to join our team. In this role, you will operate advanced computed tomography (CT) equipment to produce detailed diagnostic images, ensuring high-quality care and accurate results for patients.Key Responsibilities:Prepare patients for CT scan procedures by explaining the process, answering questions, and positioning them correctly.Operate CT scan equipment to capture high-quality diagnostic images while ensuring patient safety and comfort.Administer contrast materials when necessary to enhance imaging results, following established safety protocols.Collaborate with physicians to analyze imaging results and provide accurate diagnostic support.Maintain and calibrate CT equipment to ensure optimal performance and compliance with safety standards.Document procedures and maintain accurate patient records in compliance with regulatory requirements.Work Environment:Work in hospitals, diagnostic imaging centers, or outpatient facilities equipped with advanced CT technology.Engage in a fast-paced environment requiring attention to detail and technical expertise.Collaborate with a multidisciplinary team dedicated to delivering exceptional patient care.Benefits:Competitive salary and comprehensive benefits package.Access to cutting-edge technology and ongoing training opportunities.A supportive work environment focused on professional growth and innovation.*This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*

Your Role The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Behavioral Health will report to the Senior Medical Director, Behavioral Health. In this role you will have core responsibilities in the areas of behavioral health concurrent review, pre- and post-service utilization review, and collaboration with Clinical Care Managers. 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: Review concurrent, pre- and post-service behavioral health service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP (Federal Employee Program) medical policy, as well as legal and regulatory requirementsMedical decision and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely dischargesEngage in telephonic peer-to-peer discussions regarding current members in various levels of care or who may be receiving other specialized services. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providersTrain BSC utilization and care management staff which may include physicians, psychologists, nurses, social workers, and others as neededPerform clinical reviews to support utilization management and fraud waste and abuse case evaluationsParticipate with the quality management function in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes for our membersParticipate on projects and committees, as necessaryYour Knowledge and ExperienceMinimum 5 years direct patient behavioral health clinical care experience post residency requiredMedical degree (M.D./D.O.)Completed residency in PsychiatryMaintain active, unrestricted California Medical License required; Maintain active, unrestricted Medical License in all additional assigned states requiredMaintain Board Certification in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP) requiredPreferred Qualifications:Recent inpatient psychiatric hospital experience (within the past five years)Recent substance use disorders treatment experience (within the past five years)Well-versed with most areas of behavioral health services and conditionsShow ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issuesExperience with CPT coding, medical claims review, hospital billing, and reimbursementDeep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855 and all regulatory and compliance requirementsManaged care experience supporting utilization management, case review, and/or quality improvement activities in behavioral healthExperience with ASAM, LOCUS, CALOCUS, and WPATH

Occupational Therapist - RehabWe are seeking a compassionate and skilled Occupational Therapist to join our rehabilitation team. In this role, you will help individuals regain independence by developing and implementing customized programs to improve daily living and vocational skills.Key Responsibilities:Assess patients' needs and develop individualized treatment plans.Use therapeutic techniques to improve patients' abilities to perform daily tasks.Adapt environments and modify tasks to remove barriers for patients.Teach patients and caregivers strategies for improving functionality and independence.Document patient progress and adjust treatment plans as necessary.Work Environment:Work in rehabilitation centers, hospitals, or outpatient clinics.Collaborate with a multidisciplinary team focused on patient recovery.Benefits:Competitive salary and comprehensive benefits package.Opportunities for professional development and continuing education.A supportive work environment that values innovation and teamwork.*This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*

Your Role The Behavioral Health Registered Nurse Case Manager will report to the FEP Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member’s needs. The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians. documentation.Your Work In this role, you will: Coordinates care for Lower Level of Care such as Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, other outpatient services, and community programs as appropriate.Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying withcontract for each appropriate plan typeProvide Referrals to QualityManagement (QM), Disease Management (DM) and Appeals and Grievance department (AGD)Recognize the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamDesign appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomesInitiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settingsApplies detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health.Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation.Your Knowledge and Experience Requires a current CA RN LicenseCertified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirementsRequires at least 5 years of prior experience in nursing, healthcare or related fieldBachelor of Science in Nursing or advanced degree preferred.Requires relevant behavioral health experience.Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources.Able to operate PC-based software programs including proficiency in Word and Excel.Strong clinical documentation skills, independent problem identification and resolution skills.Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills.Competent understanding of NCQA and federal regulatory requirements.Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable.Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care.Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.

Radiology Technologist - CT Scan TechWe are seeking a skilled Radiology Technologist specializing in CT Scans to join our team. In this role, you will operate advanced computed tomography (CT) equipment to produce detailed diagnostic images, ensuring high-quality care and accurate results for patients.Key Responsibilities:Prepare patients for CT scan procedures by explaining the process, answering questions, and positioning them correctly.Operate CT scan equipment to capture high-quality diagnostic images while ensuring patient safety and comfort.Administer contrast materials when necessary to enhance imaging results, following established safety protocols.Collaborate with physicians to analyze imaging results and provide accurate diagnostic support.Maintain and calibrate CT equipment to ensure optimal performance and compliance with safety standards.Document procedures and maintain accurate patient records in compliance with regulatory requirements.Work Environment:Work in hospitals, diagnostic imaging centers, or outpatient facilities equipped with advanced CT technology.Engage in a fast-paced environment requiring attention to detail and technical expertise.Collaborate with a multidisciplinary team dedicated to delivering exceptional patient care.Benefits:Competitive salary and comprehensive benefits package.Access to cutting-edge technology and ongoing training opportunities.A supportive work environment focused on professional growth and innovation.*This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*

Your Role Reporting to the Manager, Care Management- Behavioral Health, the Licensed Clinician, Senior (ABA Case Manager) helps members with behavioral health needs navigate the health care system for linkages to behavioral health providers, treatment, and programs. This role is ideal for professionals with a background and experience in Applied Behavioral Analysis and passion for ensuring access to high quality behavioral health services. The ABA Case Manager will coordinate care and services for families, supporting members and families through their care. The ABA Case Manager will offer support in assessing members’ emotional and psychological well-being and providing resource coordination, crisis intervention, and with any general behavioral or mental health referrals. The position requires an intensive focus on crisis intervention and counseling, problem-solving and conflict resolution, patient and family management, interdisciplinary collaboration, psychosocial assessments, education, advocacy, and community resource linkages.Your WorkIn this role, you will:Collaborate with other Case Managers and Utilization Management tocomplete member assessments related to social and resource needs tosupportmemberaccess to servicesCollaborate with service coordination staff and act as liaison to ensure a timely and accurate response to member needsCollaborate with providers to support members’ treatment plan and care needsRecognize the client’s right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamAssessmembers health behaviors, cultural influences and clients belief/value systemand evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriersEfficiently manages and maintains a caseload of members for behavioral health care coordination and or BH case management for persons experiencing severe and persistent mental illness as well as members seeking and utilizing ABA services.Maintains an active workload in accordance with National Care Manager performance standards.Provides information to members and providers regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, and company policies and procedures, and criteria.Interacts with Utilization department and Physician Advisors to discuss clinical questions and concerns regarding specific cases.Coordinates services with state and community programs on behalf of the member, particularly when the member is unable to effectively do so independentlyAs a mandated reporter, files and follows-up on reports made to the appropriate government agency (e.g., Adult Protective Services, Child Protective Services, etc.)Actively participates in Interdisciplinary Team Meetings and case consultations with Licensed Manager.)Your Knowledge and ExperienceCurrent unrestricted CA License (LCSW, LMFT, LPCC, Registered Nurse (RN), or PsyD by the Board of Behavioral Health Sciences requiredRequires at least 5 years of prior relevant experience including 3 years of experience in behavioral health or ABA, case management.Advanced degree commensurate with field is preferredBCBA PreferredExperience conducting thorough psychosocial assessments, developing care plans and providing necessary interventions identified during assessment with complex client populations that may have, among other things, inadequate coping skills, severe emotional disorders, developmental disabilities, mental illnesses, and/or unstable housingConsiderable knowledge of a wide range of psychosocial challenges and familiarity with behavioral health diagnoses and treatmentPrevious health plan or insurance experience preferred.Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

Sonography - Echo Tech/Cardiac SonographerWe are seeking a skilled Cardiac Sonographer to join our team. In this role, you will use advanced ultrasound technology to create detailed images of the heart, assisting physicians in diagnosing and treating cardiovascular conditions.Key Responsibilities:Perform echocardiograms to assess heart function, including chamber size, valve function, and blood flow.Collaborate with physicians to analyze echocardiogram results and provide diagnostic support.Prepare patients for procedures by explaining the process and ensuring their comfort.Maintain and calibrate ultrasound equipment to ensure accurate imaging results.Document findings and maintain accurate patient records in compliance with healthcare standards.Assist with scheduling appointments and ensure proper cleaning of equipment after use.Work Environment:Work in hospitals, outpatient clinics, or diagnostic laboratories equipped with advanced imaging technology.Engage in a fast-paced environment requiring attention to detail and technical expertise.Benefits:A competitive salary with comprehensive benefits options available.Opportunities for professional growth through training and certifications in cardiac sonography.A supportive workplace culture focused on collaboration and innovation in patient care delivery systems.*This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*

Your Role The Behavioral Health Utilization Management team performs prospective, concurrent, retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business. The Licensed Clinician, Senior, will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role you will conduct clinical review of mental health and substance use authorization requests at various levels of care for medical necessity, coding accuracy, medical policy compliance and contract compliance.Your Work In this role, you will: Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members admitted to inpatient facilities using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare as neededGather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director oversight and necessity determinationProvide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteriaWork with multidisciplinary teams to support members using an integrated team-based approach including Interdisciplinary Team Meetings and case consultations with Medical Director and/or Licensed ManagerRecognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsYour Knowledge and Experience Bachelor of Science or advanced degree preferredCurrent unrestricted CA license (LCSW, LMFT, LPCC, Licensed Psychologist, or Registered Nurse (RN) with Behavioral Health experience)Requires at least five (5) years of prior experience in healthcare related fieldThree (3) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferredStrong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelinesFamiliarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab resultsProficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databasesExcellent analytical, communication skills, written skills, time management, and organizational skillsPossess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiativeAbility to identify problems and works towards problem resolution independently, seeking guidance as needed

Registered Nurse (RN) - Labor and Delivery Join our team as a compassionate Registered Nurse (RN) in Labor and Delivery, where you will provide specialized care to expectant mothers during childbirth and postpartum recovery. This role involves supporting families during critical moments of their lives. Key Responsibilities: Assess and monitor the health status of pregnant women during labor, ensuring timely interventions when necessary.Administer medications and treatments as prescribed by physicians, monitoring patients for any adverse reactions.Support patients during delivery, providing emotional support and guidance throughout the process.Collaborate with healthcare teams to develop individualized care plans for mothers and newborns.Educate patients and families on postpartum care, breastfeeding techniques, and newborn care strategies.Document patient information accurately in medical records, ensuring compliance with regulatory standards. Work Environment: The role is based in hospital labor and delivery units where RNs work closely with expectant mothers and newborns.This position requires strong communication skills and the ability to work effectively in a dynamic, fast-paced environment. Benefits: A competitive salary with opportunities for career advancement within obstetric nursing specialties.A comprehensive benefits package including health insurance, retirement savings plans, and paid time off.Support for continuing education programs to maintain licensure and enhance expertise in labor and delivery nursing practices. Equal Opportunity Employer: Your dedication to supporting maternal health is valued here. We strive to create an inclusive environment where all employees can thrive professionally while delivering exceptional care during critical moments of childbirth. *This information is based on general job descriptions. Actual job responsibilities may vary by location.*

Your Role The Behavioral Health Utilization Management team performs prospective & concurrent utilization reviews and first level determinations for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business. The Behavioral Health Utilization Management Clinician, Experienced, will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role you will conduct clinical review of mental health and substance use authorization requests at various levels of care for medical necessity, coding accuracy, medical policy compliance and contract compliance.Your WorkIn this role, you will:Perform prospective & concurrent utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare as neededGather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director oversight and necessity determinationProvide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteriaWork with multidisciplinary teams to support members using an integrated team-based approach including Interdisciplinary Team Meetings and case consultations with Medical Director and/or Licensed ManagerRecognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsYour Knowledge and ExperienceCurrent unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) requiredAdvanced degree commensurate with field is preferredRequires at least three (3) years of prior experience in healthcare related fieldOne (1) year conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferredStrong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelinesFamiliarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab resultsProficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databasesExcellent analytical, communication skills, written skills, time management, and organizational skillsPossess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiativeAbility to identify problems and works towards problem resolution independently, seeking guidance as needed

Registered Nurse (RN) - Labor and Delivery Join our team as a compassionate Registered Nurse (RN) in Labor and Delivery, where you will provide specialized care to expectant mothers during childbirth and postpartum recovery. This role involves supporting families during critical moments of their lives. Key Responsibilities: Assess and monitor the health status of pregnant women during labor, ensuring timely interventions when necessary.Administer medications and treatments as prescribed by physicians, monitoring patients for any adverse reactions.Support patients during delivery, providing emotional support and guidance throughout the process.Collaborate with healthcare teams to develop individualized care plans for mothers and newborns.Educate patients and families on postpartum care, breastfeeding techniques, and newborn care strategies.Document patient information accurately in medical records, ensuring compliance with regulatory standards. Work Environment: The role is based in hospital labor and delivery units where RNs work closely with expectant mothers and newborns.This position requires strong communication skills and the ability to work effectively in a dynamic, fast-paced environment. Benefits: A competitive salary with opportunities for career advancement within obstetric nursing specialties.A comprehensive benefits package including health insurance, retirement savings plans, and paid time off.Support for continuing education programs to maintain licensure and enhance expertise in labor and delivery nursing practices. Equal Opportunity Employer: Your dedication to supporting maternal health is valued here. We strive to create an inclusive environment where all employees can thrive professionally while delivering exceptional care during critical moments of childbirth. *This information is based on general job descriptions. Actual job responsibilities may vary by location.*

Your Role The Behavioral Health Utilization Management team performs prospective & concurrent utilization reviews and first level determinations for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business. The Behavioral Health Utilization Management Clinician, Senior, will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role you will conduct clinical review of mental health and substance use authorization requests at various levels of care for medical necessity, coding accuracy, medical policy compliance and contract compliance.Your Work In this role, you will: Perform prospective & concurrent utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare as neededGather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director oversight and necessity determinationProvide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteriaWork with multidisciplinary teams to support members using an integrated team-based approach including Interdisciplinary Team Meetings and case consultations with Medical Director and/or Licensed ManagerRecognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsYour Knowledge and Experience Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) requiredAdvanced degree commensurate with field is preferredRequires at least five (5) years of prior experience in healthcare related fieldThree (3) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment requiredStrong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelinesFamiliarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab resultsProficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databasesExcellent analytical, communication skills, written skills, time management, and organizational skillsPossess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiativeAbility to identify problems and works towards problem resolution independently, seeking guidance as needed

Registered Nurse (RN) - Operating Room (OR) We are seeking a skilled Registered Nurse (RN) for our Operating Room (OR), where you will assist surgical teams in providing safe and effective patient care during various surgical procedures. Key Responsibilities: Prepare operating rooms by sterilizing instruments, setting up equipment, and ensuring all necessary supplies are available.Assist surgeons during procedures by maintaining sterile fields and handing instruments efficiently.Monitor patient vital signs throughout surgery and respond promptly to any changes or complications.Coordinate with surgical teams to develop individualized patient care plans before, during, and after surgery.Provide patient education regarding surgical procedures, recovery expectations, and postoperative care instructions.Accurately document surgical procedures and patient responses in medical records. Work Environment: This position is based in hospital operating rooms or outpatient surgical centers equipped with advanced surgical technology.The role requires precision, teamwork, and the ability to perform effectively in high-stress environments. Benefits: A competitive salary with opportunities for advancement within perioperative nursing specialties.A comprehensive benefits package including health insurance, retirement plans, and paid time off.Support for continuing education programs to maintain licensure and enhance operating room nursing skills. Equal Opportunity Employer: Your dedication to surgical excellence is valued here. We strive for an inclusive environment where all employees can excel professionally while contributing significantly to patient outcomes during surgery. *This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*

Registered Nurse (RN) - Telemetry Join our team as a skilled Registered Nurse (RN) in the Telemetry Unit, where you will provide specialized care to patients requiring continuous cardiac monitoring. This role involves using advanced telemetry technology to monitor patients' vital signs and ensure timely interventions. Key Responsibilities: Monitor patients' cardiac rhythms using telemetry equipment and respond promptly to any abnormalities or emergencies.Administer medications, fluids, and treatments per physician orders while ensuring patient safety and comfort.Create personalized care plans in collaboration with interdisciplinary healthcare teams.Educate patients and families about cardiac health, treatment plans, and recovery processes.Document patient information accurately in medical records systems while adhering to regulatory standards. Work Environment: The role is based in hospital telemetry units or cardiac care centers equipped with advanced monitoring technology for critical patients requiring continuous observation.This position requires strong decision-making skills and composure under pressure in fast-paced environments focused on cardiac care excellence. Benefits: A competitive salary with potential for career growth within telemetry nursing specialties or leadership roles.A comprehensive benefits package including health insurance coverage, retirement savings options, and paid leave policies.Supportive continuing education resources designed to maintain licensure requirements and enhance telemetry nursing competencies. Equal Opportunity Employer: Your commitment to delivering high-quality patient care is greatly appreciated. We are dedicated to fostering an inclusive workplace culture where every employee can thrive professionally while positively impacting patient health outcomes daily. *This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*

Your Role The Network Contracting and Trend Analytics (NTA) team supports the Network Management team with analytical and financial modeling for provider contracting and network development activities for Blue Shield of California. The Senior Principal, Medical Informatics of NTA will report to the Senior Director of NTA. In this role you will be responsible for behavioral health finance analytics including measurement of internal cost of healthcare and reporting, analytics supporting coordination of care opportunities, and oversight of provider contracting analytics. 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: Develop the financial management and modeling best practices, specifically for Behavior Health as we move to an in-sourced environmentImplement on-going behavior health costs analysis and trendsBe responsible for CoHC - Behavior HealthBe the lead on modeling the financial aspects. Example, evaluating the financial aspects of care activities such as hospital ER vs behavioral health servicesLead all financial aspects in developing Value-Based Contracting, specifically in Behavior Health marketplace.Be accountable for development of the financial contractual arrangements and the implementation of these providers, which we are bringing in house Your Knowledge and Experience Requires a college degree or equivalent experienceMPH, MBA, MS, MA, RN, or RHIA preferredRequires 10 years of relative experienceRequires a minimum of 5 years’ experience in Health Care (managed care, academic, or gov't payer)Requires contracting in healthcare with a behavioral health specialtyRequires experience developing programs that will translate into CoHC savings specifically in extensive vendor knowledge of financial healthcare within behavioral healthRequires experience with behavioral health financial reporting and modelingRequires one to be comfortable with an ever changing business model that is continually seeking the optimal solution in the behavioral health spaceRequires a SAS Certified Base Programmer Credential or equivalent or a SAS Certified Advanced Programmer Credential or equivalent

Registered Nurse (RN) - Emergency Room (ER) Join our team as a dedicated Registered Nurse (RN) in the Emergency Room (ER), where you will provide critical care to patients with acute illnesses or injuries, ensuring timely and effective treatment in a fast-paced environment. Key Responsibilities: Rapidly assess and triage patients to determine the urgency of care required.Administer medications and treatments as needed, often in high-pressure situations.Perform emergency procedures such as wound care, intubation, or defibrillation.Collaborate with healthcare teams to develop and implement patient care plans.Educate patients and families on post-treatment care and follow-up instructions.Maintain accurate and detailed patient records. Work Environment: The role is based in emergency departments where RNs work closely with patients requiring immediate care.This position demands strong decision-making skills and the ability to work effectively in a dynamic, high-stress environment. Benefits: A competitive salary with opportunities for career advancement within emergency nursing specialties.A comprehensive benefits package including health insurance, retirement savings plans, and paid time off.Support for continuing education programs to maintain licensure and enhance expertise in emergency care practices. Equal Opportunity Employer: Your dedication to providing emergency care is valued here. We strive to create an inclusive environment where all employees can thrive professionally while contributing meaningfully to patient outcomes during critical moments of need. *This information is based on general job descriptions. Actual job responsibilities may vary by location.*