Current jobs related to Director, Medicare - Rancho Cordova CA United States - Blue Shield of California
-
Director, Medicare
4 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeDirector, Medicare & Medi-Cal Utilization Management at Blue Shield of California summary: The Director of Medicare & Medi-Cal Utilization Management plays a vital role in the success of Blue Shield of California by overseeing utilization management and care coordination for Medicare and Medi-Cal beneficiaries. This position involves managing prior...
-
Director, Medicare
3 weeks ago
Rancho Cordova, CA, United States Hobbsnews Full timeYour 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...
-
Director, Medicare
3 months ago
United States, CA, Rancho Cordova Blue Shield of California Full timeYour 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...
-
Director, Medicare
3 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
-
Director, Medicare
3 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
-
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the Role">We are seeking a skilled Healthcare Operations Director to lead our Medicare and Medi-Cal Utilization Management team at Blue Shield of California. As a critical member of our organization, you will play a key role in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal...
-
Blue Shield of California | Director, Medicare
1 month ago
rancho cordova, United States Blue Shield of California Full timeYour 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...
-
Executive Healthcare Strategist
4 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the Role:The Director, Medicare & Medi-Cal Utilization Management plays a pivotal part in the success of Blue Shield of California by overseeing utilization management and care coordination for Medicare and Medi-Cal beneficiaries.This position involves managing prior authorization processes, developing UM strategies using data analytics, and ensuring...
-
Medical Director, Utilization Management
3 weeks ago
Rancho Cordova, CA, United States Blue Shield of CA Full timeYour 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, Utilization Management will report to the Sr. Medical Director, Utilization Management. In this role, you will deliver and...
-
Rancho Cordova, California, United States Blue Shield of California Full timeAs a key member of the Blue Shield of California team, you will play a vital role in overseeing medical operations for our Medicare and Medi-Cal beneficiaries.About the RoleThis is an exceptional opportunity to lead strategic initiatives and drive operational excellence in utilization management and care coordination. You will be responsible for managing...
-
Los Angeles, CA, United States Blue Shield of CA Full timeYour Role The Senior Director, Risk Adjustment and Medicare STARs role will lead the Medicare Risk Adjustment and Stars programs, two functions that drive appropriate revenue and are thus critical to the growth and financial viability of competitive Medicare products. This leader will develop the programs and take accountability by partnering with C-suite...
-
Pharmacy Account Director, Medicare
3 weeks ago
Wallingford, CT, United States The Elevance Health Companies, Inc. Full timePharmacy Account Director, Medicare Locations: CT-WALLINGFORD, 108 LEIGUS RDMO-ST LOUIS, 1831 CHESTNUT STIN-INDIANAPOLIS, 220 VIRGINIA AVEFL-NORTH MIAMI BEACH, 1600 NE MIAMI GARDENS DR.RI-SMITHFIELD, 37 THURBER BLVD, STE 108 Time Type: Full timePosted On: Posted 7 Days AgoEnd Date: November 29, 2024 (23 days left to apply)Job Requisition ID: JR133863...
-
Healthcare Operations Director
4 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryWe are seeking a seasoned Healthcare Operations Director to oversee Utilization Management and care coordination for Medicare and Medi-Cal beneficiaries at Blue Shield of California. As a key member of our team, you will be responsible for managing prior authorization processes, developing UM strategies using data analytics, and ensuring...
-
California, MO, United States Hobbsnews Full timeYour Role The Senior Director, Risk Adjustment and Medicare STARs role will lead the Medicare Risk Adjustment and Stars programs, two functions that drive appropriate revenue and are thus critical to the growth and financially viable and competitive Medicare products. This leader will develop the programs and take accountability by partnering with C-suite...
-
Baltimore, MD, United States Blue Shield of CA Full timeYour Role The Senior Director, Risk Adjustment and Medicare STARs role will lead the Medicare Risk Adjustment and Stars programs, two functions that drive appropriate revenue and thus critical to the growth and financially viable and competitive Medicare products. This leader will develop the programs and take accountability by partnering with C-suite...
-
Medical Director, Behavioral Health
1 month ago
Rancho Cordova, CA, United States Blue Shield of California Full timeYour 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...
-
Medical Director, Behavioral Health
4 weeks ago
Rancho Cordova, CA, United States Blue Shield of California Full timeMedical Director, Behavioral Health at Blue Shield of California summary: The Medical Director of Behavioral Health at Blue Shield plays a critical role in ensuring the quality and efficiency of mental health services. Responsibilities include overseeing pre- and post-service utilization reviews, collaborating with healthcare providers, and training care...
-
Medical Director, Behavioral Health
2 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
-
Lead Behavioral Health Services Director
4 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryThe Medical Director of Behavioral Health plays a pivotal role in ensuring the quality and efficiency of mental health services. As a key member of our team, you will oversee pre- and post-service utilization reviews, collaborate with healthcare providers to deliver high-quality care, and train care management staff to ensure compliance with...
-
Clinical Compliance Director, Regulatory Affairs
3 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryWe are seeking an experienced Clinical Compliance Director to join our team at Blue Shield of California. This role will oversee the development and maintenance of our audit playbook for all lines of business, ensuring compliance with regulatory requirements.About the RoleDevelop new perspectives and innovative approaches on existing problems;...
Director, Medicare
1 month ago
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 License
* Bachelor's of Science in Nursing or advanced degree preferred
* Master's degree or equivalent experience preferred
* Minimum of 10 years of Utilization Management or relevant experience, including 6 years of management experience
* Minimum of 5 years of progressive leadership in Utilization Management operations
* Health plan or similar health care organization structure experience required
* Successful track record in driving organizational change management
* Excellent relationship and consensus-building skills required
Pay Range:
The pay range for this role is: $ 165990.00 to $ 248930.00 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.
#LI-SS8
