Utilization Management Nurse Manager
- Blue Shield of California
- | Pomona, CA
$68,644 per year |
OTHER |
July 24th, 2025
-
Blue Shield of California -
Pomona, CA
-
$68,644 per year
-
OTHER
-
July 24th, 2025
Your Role
The Facility Compliance Review (FCR) team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events. The Manager, Utilization Management Nurse Management will report to the Senior Manager, Facility Compliance Review. In this role you will be responsible for several direct reports, be a resource for problem solving issues, training and updating documentation as needed. You will work to enhance the department's operations with efficiency and attention to detail/quality.
Your Work
In this role, you will:
- Establish operational objectives for department or functional area and participate with other managers to establish group objectives
- Be responsible for team, department or functional area results in terms of planning, cost in collaboration with Sr Manager
- Develop and maintain FCR workflows, protocols, and policies to ensure efficient and effective care coordination
- Ensure workflow procedures and guidelines are clearly documented and communicated
- Interpret or initiate changes in guidelines/policies/procedures
- Monitor and evaluate the performance of the FCR team and implement improvement strategies as needed
- Keeps team focused on specific and measurable performance goals and monitors performance against clear standards.
- Works collaboratively among business units to align and partner with others to achieve performance goals and/or outcomes
- Provide Ensure the delivery of high-quality, patient-centered care through the management of chronic disease, complex case management, and discharge planning
- Other duties as assigned by Sr Manager
Your Knowledge and Experience
- Requires a current CA RN License
- Bachelors of Science in Nursing or advanced degree preferred.
- 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
- A minimum of 3+ year experience in inpatient or managed care environment preferred
- Excellent communication, interpersonal, and negotiation skills
- Has functional expertise within the area of responsibility.
- Knowledge of NCQA requirements preferred
- Ability to analyze data and create reports to guide decision-making and process improvements
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