Job Description:

Business Unit: Health Care Quality & Affordability

The Health Care Quality and Affordability team is made up of about 1,000 doctors, nurses, pharmacists, strategists, industry experts and innovators with a single vision - to transform the delivery of health care. Every day, we work together to improve the quality of patient care for our members while lowering health Care costs to ensure all Californians have access to the care they deserve.

How do we do it? Through partnership, innovation, and thought leadership.

We continue to expand our network of providers to ensure state-wide access to care. We evaluate analytic and digital health tools that simplify care delivery while improving member health status, health care quality and affordability as well as member and provider experience. We provide high-touch services to members from experienced clinical teams. You'll also find us collaborating with our federal and state legislative officials to help shape policy to advance our Blue Shield mission.

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Under the direction of the Blue Shield Promise Chief Medical Officer, the Senior Manager of Clinical Access Programs provides leadership, direction and oversight for Medi-Cal specific programs such as Facility Site Review and Initial Health Assessment. The Senior Manager of Clinical Access Programs leads cross-functional teams focused on the implementation of and compliance with Medi-Cal, Medicare and Cal MediConnect program requirements related to access and availability, Disability and Equality and other state and federal mandates. The Senior Manager of Clinical Access Programs acts as a Medi-Cal subject matter expert ensuring effective interface and cooperation with other business areas to implement and maintain program objectives and achieve organizational goals, as well as prepare and represent Medi-Cal programs in regulatory audits, such as the California Department of Health Care Services (DHCS) and the California Department of Managed Care (DMHC), and accreditation body surveys such as the National Committee for Quality Assurance (NCQA). The Senior Manager of Clinical Access Programs partners and supports the Quality Improvement teams in the management of the QI Program, QI Workplan and QI Evaluation, as well as ensuring compliance with NCQA accreditation requirements. The Senior Manager of Clinical Access Programs uses nursing judgement and clinical expertise to ensure program requirements are met and are effective, with the goal of members having access to care and services that are timely, accessible, safe, and adequate, and partners with provider network teams to improve overall network adequacy and availability. The Senior Manager also chairs and leads the Access and Availability subcommittee for Blue Shield Promise Health Plan. The Senior Manager of Clinical Access Programs is an effective leader of their management staff and teams, fostering inclusion and respect, as well as consistently meeting individual and department goals and metrics.

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Leads the project execution teams responsible for delivering transformational change that achieves BSC's strategic objectives. This leader is accountable for all project and program execution activities associated with overall organizational goals and strategic initiatives, as well as established regulatory requirements.

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Partner strategically and collaborate with Sr. Staff, business partners (multiple Vice Presidents & Senior Managers), IT leadership peers in defining and deploying strategies that ensures investments enable the BSC business strategies to achieve tactical and strategic goals

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Determines department priorities, considering regulatory requirements, timelines, resource requirements and budget.

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Facilitates all aspects of department governance, including alignment with senior and executive leadership, and ensuring robust data-centered execution, decision making, and oversight is maintained.

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Responsible for ongoing improvements of processes, systems or products to enhance performance of function, achieve and maintain regulatory compliance, as well as improve the member and provider experience.

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Requires the ability to effectively represent Blue Shield Promise at state level meetings.

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Requires the ability to represent Blue Shield Promise externally and work collaboratively with external partners, including The California Department of Health Care Services, Department of Managed Health Care, other Managed Care Plans, as well as community and provider partners.

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Exerts significant decision-making authority, guided by resource availability and functional objectives.

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Leads management team to ensure department goals and metrics are consistently achieved.

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Responsible for creating workforce and staffing plans to ensure availability of human capital necessary to accomplish departmental business goals and metrics, as well as achieve and maintain compliance with regulatory requirements.

Minimum Education & Experience Requirements:

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Registered Nurse with a current, valid California license required

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A minimum of a bachelor's degree or equivalent experience

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A minimum of 10 years relevant experience

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A minimum of 4 years management and/or leadership experience

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Prior Health Plan experience, preferably government programs

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Strong program management skills required.

Preferences:

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Master's degree preferred

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Health Plan leadership experience

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Department of Health Care Services Certified Site Reviewer or Certified Master Trainer, or the ability to achieve certification within the first year of employment

Knowledge and Skills:

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Mastery level health care industry knowledge and skill set within the professional discipline

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Requires business acumen, strategic thinking, analytical skills and decision-making skills

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Broad management knowledge to lead clinical and project teams

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Excellent written and verbal communication skills

Additional Information

- Our Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!

- Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

- Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the

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