Manager, Utilization Management Nurse Management - Mather California

Company: Blue Shield of California
Location: Mather, California
Posted On: 06/30/2025

Your Role The Medical Care Solutions Post Service Clinical Review team is hiring one RN Manager who will be responsible for leading the clinical team that reviews post service and provider appeal cases for Commercial Behavioral Health reviews The RN Manager will report to the Senior RN Manager. In this role you will be responsible for inventory management, staffing, transformation readiness, audit readiness, reporting, special projects, compliance, training and documentation updates as well s be a resource for problem solving issues. 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: Establish operational objectives for department and/or functional areas and participate with managers and stakeholders to establish shared objectives Be responsible for team, functional area quality and compliance results. Prepare files for regulatory and internal audits. Participate in regulatory and internal audits when necessary Adhere to the team’s annual budget and participate in budget planning under the direction of the team’s Manager and Director Ensure all work-flow procedures and guidelines are clearly documented, updated, and communicated timely to the team Interpret or initiate changes in guidelines/policies/procedures Develop and implement recommendations for improvement of quality and production Stay current on regulatory changes and industry requirements Responsible for reporting and analysis, Post Service workflows, protocols, policies to ensure efficient and effective care coordination Collaborate with internal business partners Your Knowledge and Experience Bachelor of Science in Nursing or advanced degree preferred. Requires a current CA RN license Requires at least 7 years of prior relevant experience including 3 years of management experience gained as a team leader, supervisor, or project/program manager Has functional expertise within the area of responsibility Behavioral Health experience preferred Experience with data analysis, trending, and inventory management preferred Regulatory audit experience with file preps, presentation, and CAP resolution preferred Understands basic management approaches such as work scheduling, prioritizing, coaching, and process execution, work organization, risk management, and delegation More...

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