Manager, Utilization Management Nurse Management

Manager, Utilization Management Nurse Management at Blue Shield of California summary :

An RN Manager leads a clinical team reviewing post-service and provider appeal cases within Commercial Behavioral Health, ensuring compliance, quality, and efficient care coordination. Responsibilities include overseeing staffing, inventory management, audits, reporting, policy updates, and continuous improvement initiatives. This role requires nursing expertise, management experience, regulatory knowledge, and collaboration with internal stakeholders to achieve operational objectives.

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

Keywords :

Utilization Management, Behavioral Health Nursing, Clinical Team Leadership, Regulatory Compliance, Staffing and Inventory Management, Audit Preparation, Post Service Review, Quality Improvement, Healthcare Reporting, Care Coordination