Manager, Program Management Clinical

Your Role

The Behavioral Health Utilization Management team performs prospective utilization review for our members and correctly applies the guidelines for nationally recognized levels of care. They collaborate directly with the Member, Member's Family, and Interdisciplinary Care Team to achieve consensus and promote positive Member health outcomes through the assessment, planning, implementation, and evaluation of the Member’s Care Plan. The Promise Health Plan Manager, Program Management Clinical will report to the Senior Manager, Program Management Clinical. In this role you will be responsible for overseeing the day-to-day operations of the Blue Shield Promise Behavioral Health Treatment (BHT/ABA) team and execution of departmental goals and objectives. The goal of which is to promote the delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits across the continuum of care. 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:

• Oversee the Behavioral Health Treatment program including daily operations, program development, and adherence to compliance
• 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
• Participate in the development and implementation of the annual budget under the direction of Sr Manager / Director 
• Ensure work flow procedures and guidelines are clearly documented and communicated 
• Interpret or initiate changes in guidelines/policies/procedures 
• Be responsible for the daily operations of the Promise Behavioral Health Utilization Management department including staffing, work scheduled, assignments, efficient workflow, and performance
• Provide leadership to ensure best utilization of resources in obtaining organization goals, regulatory compliance, with corporate policies and to ensure the needs of the individuals serves are met
• May lead special projects/committees/task forces which require Collaboration with internal business partners relating to Utilization Management, Delegation Oversight, Claims and Customer Service
• Ability to stay current on regulatory changes and industry requirements and to design and implement tools and materials that are compliant with contractual, regulatory, legislative and Blue Shield mandated requirements
• Ability to design work plans and workflows to facilitate audit and quality initiatives and be able to report and analyze oversight metrics and make process recommendations where appropriate

Your Knowledge and Experience

• Requires a master’s degree in psychology or a related field
• Requires an active California Board Certified Behavior Analyst certification
• Requires at least 7 years of experience as a BCBA (Board Certified Behavior Analyst certification)
• Requires 3 years of management experience
• Understands basic management approaches such as work scheduling, prioritizing, coaching and process execution, work organization, risk management and delegation
• Has functional expertise within the area of responsibility (Outpatient Prior Authorization Medical Necessity Determinations) and ability to work in numerous applications, with a high level of technical skills
• Typically, requires advanced knowledge of job area (Applied Behavior Analysis) usually obtained through advanced education combined with experience
• Knowledge of Medi-Cal regulatory requirements, benefits and available resources is preferred