1901 Management jobs in Los Angeles

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 

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 Utilization Management Nurse, Senior will report to the Senior Manager, Facility Compliance Review. In this role you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. This role will be focusing primarily on inpatient psych reviews for Residential Treatment and Detox. Also, you will be reviewing hospital itemized bills for a comprehensive line-by-line audit and manual claims processing on exceptions to ensure that appropriate billing practices are followed based on facility specific contract language. These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing.

Your Work

In this role, you will:

• Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP 
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance  
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements 
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate 
• Clearly communicates, is collaborative, while working effectively and efficiently 
• Review itemizations for coding logic using industry standards as well as CMS guidelines
• Triages and prioritizes cases to meet required turn-around times
• Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
• Clinical judgment and detailed knowledge of benefit plans used to complete review decisions

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience 
• Requires a current California RN License 
• Requires at least 5 years of prior relevant experience
• Previous Inpatient Psych experience preferred 
• Requires strong attention to detail to include ability to analyze claim data analytics
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Psych claims review experience preferred  

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 Utilization Management Nurse, Senior will report to the Senior Manager, Facility Compliance Review. In this role you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. This role will be focusing primarily on inpatient psych reviews for Residential Treatment and Detox. Also, you will be reviewing hospital itemized bills for a comprehensive line-by-line audit and manual claims processing on exceptions to ensure that appropriate billing practices are followed based on facility specific contract language. These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing.

Your Work

In this role, you will:

• Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP 
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance  
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements 
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate 
• Clearly communicates, is collaborative, while working effectively and efficiently 
• Review itemizations for coding logic using industry standards as well as CMS guidelines
• Triages and prioritizes cases to meet required turn-around times
• Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
• Clinical judgment and detailed knowledge of benefit plans used to complete review decisions

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience 
• Requires a current California RN License 
• Requires at least 5 years of prior relevant experience
• Previous Inpatient Psych experience preferred 
• Requires strong attention to detail to include ability to analyze claim data analytics
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Psych claims review experience preferred  

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 Utilization Management Nurse, Senior will report to the Senior Manager, Facility Compliance Review. In this role you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. This role will be focusing primarily on inpatient psych reviews for Residential Treatment and Detox. Also, you will be reviewing hospital itemized bills for a comprehensive line-by-line audit and manual claims processing on exceptions to ensure that appropriate billing practices are followed based on facility specific contract language. These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing.

Your Work

In this role, you will:

• Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP 
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance  
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements 
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate 
• Clearly communicates, is collaborative, while working effectively and efficiently 
• Review itemizations for coding logic using industry standards as well as CMS guidelines
• Triages and prioritizes cases to meet required turn-around times
• Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
• Clinical judgment and detailed knowledge of benefit plans used to complete review decisions

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience 
• Requires a current California RN License 
• Requires at least 5 years of prior relevant experience
• Previous Inpatient Psych experience preferred 
• Requires strong attention to detail to include ability to analyze claim data analytics
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Psych claims review experience preferred  

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 

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 

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 

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Senior Medical Director FEP Prior Authorization and Post Review will report to the Vice President, Medical Management or their designee. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for Federal Employee Program (FEP) membership. These functions include performance of pre-service and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.

The Senior Medical Director for FEP Prior Authorization and Post Review facilitates performance management and goals in alignment with organizational goals for the FEP membership. Moreover, this role leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California FEP members. You will also provide direction and leadership in compliance to regulatory requirements and key operational metrics and work collaboratively with the VP of Medical Management and Medical Directors in Utilization Management to achieve these goals.

Your Work

In this role, you will:

• Complete assigned clinical reviews (IP Admission and Concurrent, Lower Level of Care, Preservice requests, Post-service medical claim review, Provider Claims Disputes, Medical pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for FEP membership
• Provides clinical leadership and HR oversight for FEP Medical Director team
• Partner closely with the VP Medical Management and Medical Directors in Utilization Management to develop improved utilization of effective and appropriate services, and support operational implementation of transformation initiatives for the FEP membership
• Support VP, Medical Management and Medical Directors in Utilization Management in coordinating the care of FEP membership to provide access to high-quality health care to these members
• Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization
• Support Vice President, Medical Management in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
• Collaborate with teams in the implementation and operation of assigned initiatives
• Understands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program
• Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participates in assigned Committees
• Abides by all applicable laws and regulations as mandated by state and federal law
• Any other assigned duties

Your Knowledge and Experience

• A Medical degree (M.D./D.O.)  
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Maintain active, unrestricted California State Medical License required
• Maintain Board Certification in one of ABMS categories required (preferably Internal Medicine)
• Minimum of 2 years of previous medical leadership experience
• Minimum 5 years direct patient care experience post residency in: Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (e.g. Psychiatry, Geriatrics, OBGYN), Adult based care, Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (with 5+ years of inpatient experience), Psychiatry, Geriatrics, OBGYN
• Demonstrated proficiency in at least 3 of the following: MEDICARE/MEDICARE STARS, NCQA/URAC/Quality Programs, Policies/Procedure, Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health
• Knowledge and skilled application of national evidence-based medical necessity criteria references (MCG or InterQual)
• An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
• Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications
• Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more
• Excellent written and verbal communication skills
• Excellent analytical, time management and organizational skills
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

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