Sr. Manager, Utilization Management Nurse Management (Behavioral Health)

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 Senior Manager Utilization Management Behavioral Health will report to the Director of Behavioral Health Utilization Management and Care Management.

Your Work

In this role, you will :

Manage all aspects of day-to-day operations of the Behavioral Health UM program, including adherence to regulatory compliance and direct oversight of performance quality.

Assure compliance with appropriate regulations and oversee and assure that there are comprehensive quality processes and utilization management programs in place.

Responsible for the fiscal management of the program, including implementing and managing the budget.

Directs and oversees support, management, and mitigation of issues related to non-quantitative treatment limitations and support regulatory compliance.

Manages all aspects of MHPAEA requirements, implementation, create, and maintain supporting documentation, manage audits and information related to MHPAEA compliance.

Establish and manage workflows, project, and communication plans to support the development and maintenance of a program to assure compliance with MHPAEA, including State regulations.

May manage large projects or processes that span outside of immediate job area.

Manages all strategic planning activities of the Program with the primary goal of ensuring the ongoing effectiveness of the Program.

Establishes staffing requirements, directs recruitment, selection and when necessary disciplinary action within the Program.

Manages the Program within allocated budgetary parameters and collaborates in the development of the fiscal budget.

Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards

Your Knowledge and Experience

Current CA RN license. Bachelors of Science in Nursing or advanced degree preferred.

Requires at least 10 years of prior relevant experience

Requires 4 years of management experience which includes the supervision of clinical and professional staff, budgeting, program planning

Three (3) years conducting Utilization Management for a health insurance plan or managed care environment preferred

Strong understanding of behavioral health utilization management including application of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines

Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems / databases

Basic familiarity with accreditation bodies

Successful track record in building and maintaining positive cross-functional relationships

Aptitude for developing a quick understanding of people, processes, and technology

Excellent analytical, communication skills, written skills, time management, and organizational skills

Possess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiative

Ability to identify problems and works towards problem resolution independently, seeking guidance as needed

Pay Range :

The pay range for this role is : $ (phone number removed) to $ (phone number removed) 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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