Posted in Other 30+ days ago.
Type: Full Time
Business Unit: Health Care Quality & Affordability / Medical Care Solutions / Facility Compliance Review
The Facility Compliance Review department reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions. The team consists of 13 Nurses and 5 Nonclinical positions.
Position Summary: Sr RN Manager, Utilization and Medical Review - Ensures accurate and timely retrospective audits for contract compliance of facility claims including industry standards, authorization, medical necessity, diagnosis related grouping, hospital acquired conditions and itemized hospital billing. Oversees and directs the development, evaluation, and implementation of new or changing health care programs and clinical review of medical services for the organization using the established resources and guidelines.
Specific Responsibilities Include:
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Establishes operational objectives for department and participates with Leadership to establish group objectives.
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Responsible for team results of planning, maintain budget, and achieving cost of healthcare savings goals.
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Participates in the development and implementation of the annual budget under the direction of Leadership.
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Ensures workflow procedures and guidelines are clearly documented, maintained, and communicated.
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Interprets or may initiate changes in guidelines/policies/procedures.
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May lead special projects/committees/task forces.
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Develop and implement recommendations for improvement of quality
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Ability to stay current on regulatory changes and industry requirements.
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Participate in industry collaborative teams as needed.
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Respond to questions from Medical Groups/IPAs and provide needed guidance.
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Ability to design and implement tools and materials that are compliant with regulatory, legislative and Blue Shield mandated requirements.
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Ability to design work plans and workflows to facilitate audit and quality initiatives.
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Responsible for the reporting, analysis, and development of oversight metrics.
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Responsible for making improvements and modifications to operating policies to enhance performance of the department.
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Problems and issues faced are difficult and may require understanding of broader set of issues. May involve consideration of multiple issues, job areas or specialties and are typically solved through drawing from prior experience and analysis of issues.
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Plans and establishes goals and objectives for the department or in partnership with the department lead.
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Has direct impact on the results of the department.
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Has budgetary responsibility and/or manages certain processes or projects within department's budget.
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Manages a team (18) consisting of professionals (clinical and nonclinical).
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Leads, directs, and reviews the work of team members to accomplish operational plans and results within schedule and budget.
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Provides input for hiring, performance management and terminations of employees, in accordance with organization guidelines.
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Communicates with parties in and outside of the operational team, which may include external customers, attorneys, or vendors.
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Influences decisions which can include project and operations.
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Explains policies, practices, and procedures of the job area/department to others within the organization.
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May work to justify and gain cooperation of other parties on practices, policies, and procedures.
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Prepares and participates with legal matters to support the department process.
Minimum Education & Experience Requirements:
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RN experience is preferred
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Current CA RN License is required
- Requires a college degree or equivalent experience and minimum 7 years prior relevant experience, including 3 years of management experience gained as a team leader, supervisor, or project/program manager.
Knowledge and Skills:
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Understands management approaches such as work scheduling, prioritizing, coaching and process execution, operational metrics, risk management and delegation.
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Has functional expertise within the area of responsibility.
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Claims experience
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Leadership experience
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Advanced knowledge of job area usually obtained through advanced education combined with experience preferred.
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Arbitration experience preferred required.
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Proficient with Microsoft Office
Additional Information
- Our Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!
- Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
- 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.
- Requisition ID: 20002HQ
- Posting Date: Nov 20, 2020
- Schedule: Full-time
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