Clinical Nurse Educator, Consultant (Utilization Management)

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Job description

Your Role

The Medical Care Solutions education team is responsible for all clinical education for all departments within Medical Care Solutions as well as some Health Solutions teams. This includes Utilization Management, Care Management, Post Service, and Appeals. This clinical educator role will be responsible for Utilization Management for all lines of business. The Clinical Educator position will report to the Senior Stakeholder Manager in Enterprise Learning supporting Health Solutions.

Your Work

In this role, you will:

Manage and facilitate clinical education for new hires and existing clinical staff

Support Utilization Management with a focus on new hire training and continuing education for Blue Shield of California clinicians working concurrent review and prior authorizations

Conduct training classes in a virtual learning environment and at times in person

Act as a liaison and provide training support and clinical education to clinicians

Report any instances of noncompliance, such as access issues or quality concerns, to the appropriate department along with recommended corrective actions

Partner will quality team and compliance to address quality trends or compliance issues that require training or education with a focus on DHCS, NCQA, and DMHC regulatory compliance

Act as a Utilization Management clinical subject matter expert for Enterprise Learning guiding principles and processes

Provide learning support and create Behavioral Health clinical learning scenarios

Be a subject matter expert in MCG clinical criteria and BSC medical policies

Clinical education on Utilization Management including concurrent reviews and prior authorizations

Utilization Management concurrent review and prior authorization department processes and workflows

Develop and design training modules for Utilization Management for all lines of business

Create learning competencies checklists, mock case scenarios, and assessments as needed for Utilization Management reviews using MCG clinical guidelines and medical policies

Support clinical learning projects and process improvements for Utilization Management (Concurrent Review and Prior Authorizations)

Your Knowledge and Experience

Requires a bachelor's degree or equivalent experience

Requires a current California RN license

Requires at least 7 years of prior relevant experience

Experience working in Utilization Management, preferred

Experience in Health Insurance, preferred

Knowledge of learning principles and models, preferred

Experience facilitating presentations using virtual technology, preferred

Pay Range:

The pay range for this role is: $ (phone number removed) to $ (phone number removed) 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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