Manager, Utilization Management Nurse Management

Company: Blue Shield of California
Location: El Dorado Hills
Posted on: June 24, 2025

Job Description:

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

Keywords: Blue Shield of California, San Rafael , Manager, Utilization Management Nurse Management, Healthcare , El Dorado Hills, California