Manager, Utilization Management Nurse Management (Appeals and Grievances) - Blue Shield of California

Your Role

The Medical Care Solutions Appeals and Grievance team is hiring an RN who will be responsible for leading the clinical appeals and grievance team for the Commercial line of business. The RN manager will report to the RN Senior Manager. In this role you will be responsible for inventory management, staffing, transformation readiness, audit readiness, reporting, special projects, and compliance 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 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
• Participate in the development and implementation of the annual budget under the direction of Sr Manager / Director
• Ensure work-flow procedures and guidelines are clearly documented and communicated
• Interpret or initiate changes in guidelines/policies/procedures
• Maintain regulatory compliance
• Develop and implement recommendations for improvement of quality and production
• Stay current on regulatory changes and industry requirements
• Responsible for reporting, analysis, and oversight metrics
• Collaborate with internal business partners

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• 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
• Medi-Care experience is preferred
• Understands staff scheduling, prioritizing, coaching, and process execution
• 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

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.