Your Role

The Quality Review team completes internal audits of front-line staff and vendors to ensure alignment with department processes and regulatory compliance. Quality Reviewers also provide coaching and work closely with business leaders to drive optimal results. The Manager of Quality Review will report to the Senior Manager of the Quality & Communications team. In this role you will be responsible for leading the team in numerous quality initiatives, providing and presenting data to business unit leaders, and working closely with the Senior Manager on internal process improvement. 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:

• Be a people leader responsible for leading a small team of clinical and non-clinical Quality Reviewers, manage day-to-day operations and provide staff support
• Monitor the regulatory compliance and quality of service provided to members through internal case review
• Monitor the execution of internal processes and procedures as requested by business unit leaders; ensure compliance with regulatory, legal, and contractual requirements, as well as accreditation and Blue Shield standards
• Communicate with internal and external leaders to ensure audit tools meet all regulatory and process expectations
• Coordinate all information, provide data analysis and respond to the appropriate parties; participate and present in committee meetings
• Be responsible for strategic alignment and integration across projects/programs in support of business unit process and administrative efficiency
• Be responsible for medium complexity projects/programs, manage them from initiation through delivery and monitor for continuous improvement
• Exercise independent judgement in developing methods, techniques and evaluation criterion for obtaining results

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires at least 7 years prior relevant experience, including 3 years of management experience gained as a team leader, supervisor or project/program manager
• Requires current California RN license OR Master's Level Licensed Mental Health individual (LMFT/LCSW) & 4+ years related experience and/or training, or equivalent combination
• Requires Care/Case Management and/or Utilization Management experience, with knowledge of medical necessity criteria and applying LOCUS/CALOCUS/ECSII/ASAM guidelines
• Requires familiarity with regulatory requirements and accreditation standards for Utilization Management and Care/Case Management
• Managed Care experience strongly preferred

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.

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