Sr. Manager, Utilization Management Nurse Management

Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen. Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

The UM Prior Authorization team conducts medical necessity reviews for services before they are rendered. The Sr. Manager Medical and Utilization Review, CalPERS will report to the Director Medical and Utilization Review, CalPERS. In this client facing role you will be managing a high functioning team, have direct oversight of day-to-day operations and participate in process improvement/cost of health care initiates. 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. At Blue Shield of California, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce. Two Ways of Working: Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions: Member-facing and approved out-of-state roles remain remote. Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits. For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being. On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

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 and methods in collaboration with Director. Participate in the development and implementation of the annual budget under the direction of Director. Ensure workflow procedures and guidelines are clearly documented and communicated. Interpret or initiate changes in guidelines/policies/procedures. Engage with CalPERS leadership in resolution of member escalations and process improvement May lead special projects/committees/task forces. Manages a team and/or department with focus on policy and strategy implementation. Establishes operational plans with measurable contribution towards the achievement of results for the function. Provides measurable input to new products, processes or standards in operational plans that will have some impact on the achievement of overall function results. Exerts significant decision-making authority, guided by resource availability and functional objectives. Has budgetary responsibility and/or manages certain processes or projects within department’s budget. Responsible for making moderate to significant improvements of processes and policies to enhance performance of the department. Requires ability to exert influence on others within department in the development of multiple objectives and annual goals for a department. Influences higher-level management on large-scale tactical changes and organization improvements. Manages a large team consisting of experienced clinical professionals. Leads, directs and reviews the work of team who exercise latitude and independence in their assignments. Manage multiple regulatory reports. Manage operational and regulatory reports. Ensure compliance to regulatory and accreditation standards. Collaborate across functionally to improve member outcomes