Your Role Reporting to the Sr. Director, Utilization Management, the role of the Director, Medicare & Medi-Cal 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 the Utilization Management team in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal membership. The Director, Medicare & Medi-Cal Utilization Management role will also provide direction and leadership in compliance to regulatory requirements and key operational metrics.Your Work In this role, you will: Manages and monitors prior authorization and concurrent review to ensure that the patient is getting the right care in a timely and cost-effective way.Leading development of UM strategy by leveraging the use of data/analytics to inform and technology solutions to streamline operational efficiencies while also building a cost-benefit methodology to rationalize decisions on UM reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.Provides analysis and reports of significant utilization trends, patterns, and resource allocation.Partners with physicians and others to develop improved utilization of effective and appropriate services.Establishing and measuring productivity metrics to support workforce planning methodology and rationalization of services required to perform UM reviews.Reviewing and reporting out on Utilization Review (UR) trending for Medicare and Medi-Cal membership.Ensuring alignment of the authorization strategy with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.Responsible for managing strategic projects and supporting operations initiatives.Leading operational implementation of transformation changes (organizational management, process implementation, technology adoption).Responsible for operational 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.Ensuring all operational processes are meeting regulatory and accreditation requirements.Fosters a culture of process excellence, BSC leadership principles, and a great place to work environment.Occasional business travel required.Your Knowledge and Experience Requires current CA RN LicenseBachelor’s of Science in Nursing or advanced degree preferredMaster’s degree or equivalent experience preferredMinimum of 10 years of Utilization Management or relevant experience, including 6 years of management experienceMinimum of 5 years of progressive leadership in Utilization Management operationsHealth plan or similar health care organization structure experience requiredSuccessful track record in driving organizational change managementExcellent relationship and consensus-building skills required

Your Role The Care management team is looking for a leader with Medi-Cal experience who can help design and lead our Medi-Cal line of business. The Senior Manager of Care Management, Medi-Cal will report to the Director of Care Management in the Population Health Department.. In this role you will be will serve as the professional leader of registered nurses within Blue Shield care management who is a good collaborator, experienced in people leadership, and will serve as a mentor and advisor to senior leadership. The selected candidate will also function as the subject matter expert on professional nursing/ care management for Medi-Cal regulations- who will represent care management in initiatives, client presentations, act as a liaison between other business units within Blue Shield to bolster care management knowledge on community resources, best practices, and promote holistic and integrated approach to medical care management..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 WorkYour WorkIn this role, you will:Establish operational objectives for department or functional area andparticipatesand leads other managers to establish group objectivesBe responsible for team, department or functional area results in terms of planning, cost and methods in collaboration with DirectorParticipate in the development and implementation of the annual budget under the direction of DirectorEnsure workflow procedures and guidelines are clearly documented and communicatedInterpret or initiate changes in guidelines/policies/proceduresProvides leadership to ensure best utilization of resources in obtaining organizational goals, regulatory compliance, adhering to corporate policies through oversight of daily operations, assessment of adequacy of staffing, and adherence to standard of social workersEnhancement or creation of care management processes in compliance with regulatory requirementsMaintenance and operationalizing of the Model of Care (MOC) for Medi-Cal SPD members, Cal-AIM, and other contracts with DHCS and CMS in close collaboration with and guidance from Director of Care ManagementResponsible for ensuring that the care management department readiness for internal and external regulatory and accreditation auditsPrimary involvement with committees, projects, initiatives, professional associations, and other service providers to promote appropriate and cost-effective care delivery for the populationFocused on services and programs to increase quality of life and health of all membersMacro level collaboration and involvement with committees, projects, initiatives, community leaders, county social service personnel, professional associations, and other service providers to promote appropriate and cost-effective care delivery for the populationDemonstrates a passion for leading positive change by enhancement and sustainment of an innovative care management program that advocates for patient safety by keeping informed of mandates, regulations, and best practice innovationsEnhancement and development of client health education, Advance Healthcare Planning and End of Life counseling and support and promotes participation in staff, patient, and community educationPromotion of best practice in impacting social determinants of health and homelessnessRepresent Blue Shield care management in Blue Shield sponsored community events and fairsRegular collaboration with other Blue Shield managers in care management and other business unitsMaintain daily measurement standards and outcomes for staffAn active participant in practice transformationYour Knowledge and ExperienceRequires a bachelor's degree or equivalent experienceRequires 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 10 years of prior relevant experience including 4 years of management experience gained as a team leader, supervisor, or project/program managerRequires health insurance/managed care experience (Commercial, Medicare, and Medi-Cal).Requires excellent communication, presentation, and procedure-writing skillsLean methodology desiredAdvanced degree preferred

Your Role The Behavioral Health (BH) Utilization Management (UM) team performs prospective, concurrent, retrospective utilization reviews and first level determinations for members using BSC evidenced based guidelines, policies, and nationally recognized clinical criteria across multiple lines of business. The Behavioral Health Utilization Management, Consultant (Lead), will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role you will support the clinicians with daily operations, provide coaching, and serve as the subject matter expert for the BH UM team as they conduct clinical reviews of mental health and substance use authorization requests at various levels of care for medical necessity.Your WorkIn this role, you will:Facilitate communication between leadership, Medical Directors, and non-clinical leads to address line staff questions and issues; escalate matters to management with recommendations or consultation as neededLead onboarding/training of incoming staff, provide proactive and guided support through the onboarding processMaintain and gain knowledge of behavioral health utilization management through team and departmental expansion as neededAct as subject matter expert to review and evaluate the effectiveness of operational workflows to identify problems and develop improvements, modifications, and enhancementsDevelop and evaluate tools and materials that enhance operating efficiency, accuracy, and technical skill levels of unit staffAssist with audit readiness in collaboration with internal BSC partnersPerform advanced or complicated prior authorization and concurrent utilization reviews and first level determinations for members using non-profit association guidelines ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for oversight and necessity determinationIdentify process and control improvement opportunities and provide recommendations that help improve the effectiveness, efficiency and/or economic value of a control or processProvide guidance, coaching and training on internal behavioral health utilization management processes to other employees across the company as appropriateLead, manage, and execute other special projects and team initiatives as assignedLead team huddles/meetings to support processes and collaboration of team membersSupport 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 seven (7) years of prior experience in healthcare related fieldExperience operating in a lead role or equivalent leadership training is preferredFive (5) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferredDeep knowledge of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay clinical against nonprofit association 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

Your Role Reporting to the Manager, Care Management- Behavioral Health, the Behavioral Health Care Management Clinician, Seniorhelps members with behavioral health needs navigate the health care system for linkages to behavioral health providers, treatment, and programs. The Behavioral Health Care Manager will offer support in assessing members’ emotional and psychological well-being and providing resource coordination, crisis intervention, substance abuse, and with any behavioral or mental health referrals. The Behavioral Health Care Management Clinician, Senior will be available to physicians and nurse care managers as a consultant for patients with complex psychosocial needs. 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 Work In this role, you will: Collaborate with case managers and other team members 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.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 Experience Current unrestricted CA License (LCSW, LMFT, LPCC, Registered Nurse (RN), or PsyD by the Board of Behavioral Health Sciences requiredAdvanced degree commensurate with field is preferredRequires at least five (5) years of prior relevant experience, including three (3) years of experience in behavioral health.Certified Case Manager 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 treatmentProficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint