Blue Shield Of California is hiring: Clinical Nurse Educator, Consultant (Utiliz

Job Description

Your Role

The 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 Work

In this role, you will:

• Manage and facilitate clinical education for new hires and existing clinical staff
• Support Utilization Management with a focus on new hire training and continuing education for Blue Shield of California clinicians working concurrent review and prior authorizations
• Conduct training classes in a virtual learning environment and at times in person
• Act as a liaison and provide training support and clinical education to clinicians
• Report any instances of noncompliance, such as access issues or quality concerns, to the appropriate department along with recommended corrective actions
• Partner 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 compliance
• Act as a Utilization Management clinical subject matter expert for Enterprise Learning guiding principles and processes
• Provide learning support and create Behavioral Health clinical learning scenarios
• Be a subject matter expert in MCG clinical criteria and BSC medical policies
• Clinical education on Utilization Management including concurrent reviews and prior authorizations
• Utilization Management concurrent review and prior authorization department processes and workflows
• Develop and design training modules for Utilization Management for all lines of business
• Create learning competencies checklists, mock case scenarios, and assessments as needed for Utilization Management reviews using MCG clinical guidelines and medical policies
• Support clinical learning projects and process improvements for Utilization Management (Concurrent Review and Prior Authorizations)

Qualifications

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires a current California RN license
• Requires at least 7 years of prior relevant experience
• Experience working in Utilization Management, preferred
• Experience in Health Insurance, preferred
• Knowledge of learning principles and models, preferred
• Experience 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.

About the Team

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.

Two ways of working: Hybrid (our default) and office

• Hybrid - In a business unit approved office a few times per year to 3 days per week, on average

• Office - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an "Essential Role," the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.