Manager, Clinical Quality Review - RN

Blue Shield of California; California (MO); Hybrid; USD 100,000 - 120,000; Full time

Job summary

Join a leading healthcare organization as a Manager in Clinical Quality Review. Oversee a skilled clinical team to ensure timely and compliant healthcare services while fostering leadership and innovation. This role requires a strong background in nursing and significant experience in healthcare management, particularly in quality assurance and regulatory compliance.

Benefits

Health and wellness benefits

Flexible work environment

Qualifications

• Must possess a California RN license.
• Requires at least 7 years of relevant experience in healthcare management.
• Strong experience in operational leadership and change management.

Responsibilities

• Provide supervision to the Clinical Quality Review team.
• Ensure compliance through oversight and develop innovative service delivery approaches.
• Participate in regulatory audits and manage quality reporting.

Skills

Leadership

Communication

Critical Thinking

Education

Bachelor's degree in Nursing or related field

Job description

Join to apply for the Manager, Clinical Quality Review - RN role at Blue Shield of California

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Your Role

The Clinical Quality Review team reviews potential quality issues that are received by our members, providers, or are internally identified by staff. In collaboration with our medical directors, the team follows up / reports results to the appropriate committees for further resolution. The Manager, Clinical Quality Review, will report to the Sr. Manager, Clinical Quality Review. In this role you will be providing oversight as assigned to a clinical team comprised of Registered Nurses (RNs), Behavioral Health Clinicians and administrative staff to ensure operational compliance with timeliness and reporting requirements.

Job Description

Your Role

The Clinical Quality Review team reviews potential quality issues that are received by our members, providers, or are internally identified by staff. In collaboration with our medical directors, the team follows up / reports results to the appropriate committees for further resolution. The Manager, Clinical Quality Review, will report to the Sr. Manager, Clinical Quality Review. In this role you will be providing oversight as assigned to a clinical team comprised of Registered Nurses (RNs), Behavioral Health Clinicians and administrative staff to ensure operational compliance with timeliness and reporting requirements.

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.

Responsibilities

Your Work

• Provide supervision and ensure overall performance of team, while working to improve clinical performance outcomes
• Ensure that best practices are followed and develop innovative approaches to improve member receipt of appropriate services and provider communication
• Develop program including goals, activities, and reporting structure to assess progress, barrier identification and recommendations for improved outcomes
• Direct assessment activities to determine overall cost and quality effectiveness of interventions
• Ensure compliance with regulatory, legal, contractual requirements, accreditation and BSC standards
• Manage assigned Clinical Quality Review team to ensure clinical information/case related clinical research is obtained, reviewed, and reported out timely
• Provide oversight/manage queues and case assignments, and allocate staff appropriately
• Work with BSC medical directors to conduct clinical reviews, assign severity leveling, and prepare cases for committee review (i.e. Specialty Reviewer, Peer Review Committee (PRC) or Credentialing Committee)
• Participate in regulatory or accreditation audits, including preparing for file review audits, and presenting data to regulators
  
  

Qualifications

Your Knowledge and Experience

• Registered Nurse (RN) California license required
• Requires a bachelor's degree in nursing, Public Health, or other related field
• 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
• Required at least 3 years of Health care / Managed care experience (i.e. broad knowledge of current concepts, practices and procedures within the health care field, especially related to HMO, Medicare, Medi-Cal – with extensive Medi-Cal knowledge and experience)
• Demonstrated experience in cross-functional operational leadership and in coaching, mentoring and guiding employees in areas related to change management and operational process improvement
• Demonstrated investigative, problem solving, critical thinking and assessment skills, working knowledge of industry related systems
• Excellent communication skills, both written and oral
  
  

About The Team

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield isa U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
  
  

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
• Member-facing and approved out-of-state roles remain remote.
• Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
  
  

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.

Please click here for further physical requirement detail.

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 San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Insurance

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