Clinical Director, Utilization Management
6 days ago
The Medical Director, Operations - CalPERS will play a key role in ensuring that Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. This position will report to the Vice President, Medical Management.
Key Responsibilities- Deliver and collaborate on clinical review activities, including management of physician processes in support of utilization management and transactional functions for CalPERS membership.
- Perform pre-service, concurrent, and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.
- Facilitate performance management and goals alignment with organizational objectives for CalPERS membership.
- Lead or meaningfully contribute to Blue Shield priorities and transformative initiatives that enhance the health and wellbeing of Blue Shield of California CalPERS members.
- Provide direction and leadership in compliance with regulatory requirements and key operational metrics.
- Work collaboratively with the Director, CalPERS Utilization Management to achieve these goals.
- A Medical degree and 12 years' experience, including a minimum of 5 years' experience in active clinical practice in an adult-based primary care specialty (internal Medicine or Family Practice).
- Unrestricted California State Medical License required.
- Board Certification in one of ABMS categories, preferably Internal Medicine, required.
- 5 years' experience in managed care that can contribute to utilization management, case management, and/or quality improvement activities or other health care administrative operations at the IPA or health plan level preferred.
- Knowledge of Medicare, California statutes and regulations including DMHC and understanding of NCQA accreditation standards preferred.
- Knowledge and skilled application of National evidence-based medical necessity criteria references (MCG or InterQual) preferred.
- Experience in data analysis and key performance indicators (KPI's) to drive performance improvement preferred.
- Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others.
- Strong 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 more.
- Excellent analytical, time management, and organizational skills.
- Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint.
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Director, Commercial Utilization Management
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Rancho Cordova, California, United States Blue Shield of California Full timePosition OverviewThe Utilization Management department is responsible for evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will work under the guidance of the Utilization Management Nurse Manager. This role involves assessing clinical data from various inpatient facilities to...
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Rancho Cordova, California, United States Blue Shield of California Full timePosition OverviewThe Utilization Management department is responsible for evaluating inpatient admissions for our members, adhering to established national care standards. The Senior Utilization Management Nurse will report directly to the Nurse Manager of Utilization Management. In this capacity, you will be tasked with reviewing clinical data from various...
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Rancho Cordova, California, United States Blue Shield of California Full timePosition OverviewThe Utilization Management division is responsible for evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will work under the supervision of the Utilization Management Nurse Manager. This role involves reviewing clinical data from assigned inpatient facilities...
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Senior Nurse for Utilization Management
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Rancho Cordova, California, United States Blue Shield of California Full timeYour RoleThe Utilization Management division evaluates inpatient admissions for our members in accordance with established national care standards. The Senior Utilization Management Nurse will report directly to the Utilization Management Nurse Manager. In this capacity, you will be assigned a roster of inpatient facilities and will assess clinical data...
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Senior Nurse for Utilization Management
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Rancho Cordova, California, United States Blue Shield Of California Full timePosition OverviewThe Senior Utilization Management Nurse plays a crucial role in overseeing inpatient admissions for our members, ensuring compliance with established care standards.Key ResponsibilitiesIn this position, you will be tasked with reviewing clinical data from various inpatient facilities to assess the medical necessity of admissions, appropriate...
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Medical Director, Operations
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Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Medical Director, Operations - CalPERS will play a pivotal role in ensuring that Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. This position will report to the Vice President, Medical Management, and will be responsible for delivering and collaborating on...
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Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryThe Medical Director, Operations - CalPERS will play a critical role in ensuring that Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. This position will report to the Vice President, Medical Management.Key ResponsibilitiesClinical Review and Management: Deliver and...
