Blue Shield Of California
Blue Shield Of California is hiring: Sr. Manager, Clinical Quality Review in Ran
Blue Shield Of California, Rancho Cordova, CA, United States
Job Description
Your Role
The Clinical Quality Review team reviews potential quality issues that are received by our members, providers, or are internally identified by staff. In collaboration with our medical directors, the team and follows up / reports results to the appropriate committees for further resolution. The Sr. Manager of the Clinical Quality Review team will report to the Director of Clinical Quality - Quality Management & Assurance . In this role you will be oversighting a team of RNs and administrative staff to ensure operational compliance with timeliness and reporting requirements. You will also complete report outs to various committees on team statistics. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Work
In this role, you will:
Your Knowledge and Experience
The pay range for this role is: $ 120120.00 to $ 180180.00 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
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:
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
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.
Your Role
The Clinical Quality Review team reviews potential quality issues that are received by our members, providers, or are internally identified by staff. In collaboration with our medical directors, the team and follows up / reports results to the appropriate committees for further resolution. The Sr. Manager of the Clinical Quality Review team will report to the Director of Clinical Quality - Quality Management & Assurance . In this role you will be oversighting a team of RNs and administrative staff to ensure operational compliance with timeliness and reporting requirements. You will also complete report outs to various committees on team statistics. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Work
In this role, you will:
- Provide supervision and ensure overall performance of team, while working to improve clinical performance outcomes
- Ensure that best practices are followed and develop innovative approaches to improve member receipt of appropriate services and provider communication
- Develop program including goals, activities and reporting structure to assess progress, barrier identification and recommendations for improved outcomes
- Direct assessment activities to determine overall cost and quality effectiveness of interventions
- Responsible for identification of, chartering and assignment of new projects with assigned Business Project Manager, and provision of progress reports on clinical improvement initiatives and projects to Quality Director and Quality Committees
- Responsible for operational and strategic oversight of the Clinical Quality Review activities, which spans Blue Shield of California and Blue Shield of California Promise Health Plans
- Manages team of coordinators and nurses to ensure clinical information/case related clinical research is obtained, reviewed, and reported out timely.
- Oversights/manages queues and case assignments, and allocates staff appropriately
- Works with BSC medical directors to conduct clinical reviews, assign severity leveling, and prepare cases for committee review (i.e. Specialty Reviewer, Peer Review Committee (PRC) or Credentialing Committee)
- Represents Clinical Quality Review team/activities in regulatory or accreditation audits, including preparing for file review audits, and presenting data to regulators
Your Knowledge and Experience
- Requires a bachelor's degree in Nursing, Public Health, or other related field
- Requires at least 10 years of prior relevant experience including 4 years of management experience
- Clinical Registered Nurse (RN) California license required; master's degree preferred
- Demonstrated experience in cross-functional operational leadership and in coaching, mentoring and guiding employees in areas related to change management and operational process improvement
- Demonstrated investigative, problem solving, critical thinking and assessment skills; requires working knowledge of industry related systems (including basic applications, EMRs and systems such as EPIC, CERNER, MediTech)
- Health care / Managed care experience, i.e. broad knowledge of current concepts, practices and procedures within the health care field, especially related to HMO, Medicare and Medi-Cal
- Excellent communication skills, both written and oral
The pay range for this role is: $ 120120.00 to $ 180180.00 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
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.
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.