Blue Shield of California
Clinical Nurse Educator, Consultant (Utilization Management)
Blue Shield of California, Rancho Cordova, California, us, 95741
Your RoleThe Medical Care Solutions education team is responsible for all clinical education for all departments within Medical Care Solutions as well as some Health Solutions teams. This includes Utilization Management, Care Management, Post Service, and Appeals. This clinical educator role will be responsible for Utilization Management for all lines of business. The Clinical Educator position will report to the Senior Stakeholder Manager in Enterprise Learning supporting Health Solutions.
Your WorkIn this role, you will:
Manage and facilitate clinical education for new hires and existing clinical staffSupport Utilization Management with a focus on new hire training and continuing education for Blue Shield of California clinicians working concurrent review and prior authorizationsConduct training classes in a virtual learning environment and at times in personAct as a liaison and provide training support and clinical education to cliniciansReport any instances of noncompliance, such as access issues or quality concerns, to the appropriate department along with recommended corrective actionsPartner will quality team and compliance to address quality trends or compliance issues that require training or education with a focus on DHCS, NCQA, and DMHC regulatory complianceAct as a Utilization Management clinical subject matter expert for Enterprise Learning guiding principles and processesProvide learning support and create Behavioral Health clinical learning scenariosBe a subject matter expert in MCG clinical criteria and BSC medical policiesClinical education on Utilization Management including concurrent reviews and prior authorizationsUtilization Management concurrent review and prior authorization department processes and workflowsDevelop and design training modules for Utilization Management for all lines of businessCreate learning competencies checklists, mock case scenarios, and assessments as needed for Utilization Management reviews using MCG clinical guidelines and medical policiesSupport clinical learning projects and process improvements for Utilization Management (Concurrent Review and Prior Authorizations)Your Knowledge and Experience
Requires a bachelor's degree or equivalent experienceRequires a current California RN licenseRequires at least 7 years of prior relevant experienceExperience working in Utilization Management, preferredExperience in Health Insurance, preferredKnowledge of learning principles and models, preferredExperience facilitating presentations using virtual technology, preferred
Pay Range:The pay range for this role is: $ 109120.00 to $ 163680.00 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.
Your WorkIn this role, you will:
Manage and facilitate clinical education for new hires and existing clinical staffSupport Utilization Management with a focus on new hire training and continuing education for Blue Shield of California clinicians working concurrent review and prior authorizationsConduct training classes in a virtual learning environment and at times in personAct as a liaison and provide training support and clinical education to cliniciansReport any instances of noncompliance, such as access issues or quality concerns, to the appropriate department along with recommended corrective actionsPartner will quality team and compliance to address quality trends or compliance issues that require training or education with a focus on DHCS, NCQA, and DMHC regulatory complianceAct as a Utilization Management clinical subject matter expert for Enterprise Learning guiding principles and processesProvide learning support and create Behavioral Health clinical learning scenariosBe a subject matter expert in MCG clinical criteria and BSC medical policiesClinical education on Utilization Management including concurrent reviews and prior authorizationsUtilization Management concurrent review and prior authorization department processes and workflowsDevelop and design training modules for Utilization Management for all lines of businessCreate learning competencies checklists, mock case scenarios, and assessments as needed for Utilization Management reviews using MCG clinical guidelines and medical policiesSupport clinical learning projects and process improvements for Utilization Management (Concurrent Review and Prior Authorizations)Your Knowledge and Experience
Requires a bachelor's degree or equivalent experienceRequires a current California RN licenseRequires at least 7 years of prior relevant experienceExperience working in Utilization Management, preferredExperience in Health Insurance, preferredKnowledge of learning principles and models, preferredExperience facilitating presentations using virtual technology, preferred
Pay Range:The pay range for this role is: $ 109120.00 to $ 163680.00 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.