Blue Shield Of California
Director, Case Management Nurse Management
Blue Shield Of California, Oakland, California, United States, 94616
Job Description
Your Role
The Director of Transitional Care Services reporting to the Sr Director, Population Health Management, will work to implement whole person integrated healthcare by leading Care Management for the MediCal member population. This role will provide leadership, direction, and oversight to our Medi-Cal Transitional Care Services team and ensure that our beneficiaries receive case management interventions and linkages to essential services while residing in an inpatient setting and post-discharge. Services will include linkage to PCPs and specialist and linkage to other supportive services such as CalAIM Enhanced Care Management, CalAIM Community Supports, the Community Health Worker Benefit and Long-Term Services and Supports. This leader will support the Population Health program designed to engage members, reduce disparities and gaps in care, and improve quality for our Medi-Cal members. This position will drive member experience and engagement, improvement in the overall health of Blue Shield of California members, and affordability and efficiency. The Director contributes to the overall strategy and goals of the Medical Care Solutions organization. This role is being created in compliance with the MediCal mandate requirement outlined by the Cal-AIM Population Health Management program.
Responsibilities
Your Work
In this role, you will: Be accountable for annual strategic planning, resource planning to ensure appropriate resources are allocated to projects and are appropriately calculated in the PHM transitional care services department budget Act as a change agent for Population Health Management to improve performance results, provides organizational effectiveness leadership to achieve department goals (people/process/technology), with a focus on optimizing Transitional Be responsible for the care management team that focuses on high quality patient care and other high member touch programs within Medi-Cal line of business, with TCS integrated as a core function to support timeless coordination during inpatient stays and post-discharge outreach. Establish strong partnerships across the organization including Utilization Management, Human Resources, Planning & Finance, Control Tower, Program Delivery (Project Management Office) and IT. Coordinate PHM transitional care services team readiness for new benefits implementations with the goal of ensuring all members have access to the right care, at the right time, and at the right benefit at the right price on their effective date and all operational metrics are within agreed upon service levels. Develop and maintain a training and learning development plan Ensure ongoing business process management using continuous process improvement practices, and implementation of technology to drive greater efficiency, productivity and customer experience Ensure a culture of affordability, drives leadership principles among people managers, and ensures team actions are in place to make Blue Shield a great place to work Responsible for driving the strategic outcome of the Medi-Cal line of business for PHM Transitional Care Services. This includes the evaluation of data from multiple sources, designing and refining care coordination programs in conjunction with other clinical leaders, and reviewing key performance indicators to inform ongoing program improvement, staffing alignment, and member engagement strategies. Responsible for partnering with MediCal leadership and other market leadership to design, develop and implement key initiatives that will enhance the value and performance of the Medi-Cal product by developing products, services, processes or systems that are new to Blue Shield. This includes identifying opportunities within PHM Transitional Care Services to pilot or scale approaches that improved care coordination, member outcomes, and operational efficiency. Responsible for key PHM Transitional Care Services metrics related to compliance and contractual obligations by ensuring teams are within compliance in accordance with all regulations and contractual obligations. Develop prospective approach to maintaining audit readiness, maintaining documentation, workflows, and reporting practices that demonstrate consistent compliance and program integrity. Serve as a representative of PHM Transitional Care Services department for areas of responsibility. Lead as a subject matter expert in all regulatory requirements and operational processes related to Medi-Cal care management, with a focus on transitions of care and coordination across settings. Maintain staffing and development of PHM Transitional Care Services clinical and non-clinical staff. Works with Medi-Cal leadership and market leaders to ensure appropriate staffing ratios based on future processes and regulations. Be able to forecast staffing levels within budgetary guidelines as appropriate. Work cross functionally to start new Care Management initiatives, including those aimed at impacting on the total cost of care. Lead the identification and operationalization of initiatives across PHM and Transitional Care Services, ensuring alignment with enterprise goals. Review results from key performance indicators and adjust accordingly. Lead or participate directly in the establishment of long term functional or regional strategies in support of Blue Shield's long term business strategy Occasional business travel required. Population Health Management team members are located at four Blue Shield sites in California Qualifications
Your Knowledge and Experience
College degree or equivalent experience required. Advanced degree commensurate with field preferred. Must maintain active, unrestricted CA RN license or current LCSW, LMFT, LPCC, or PsyD by the Board of Behavioral Health Sciences A minimum of 6 years' experience successfully managing people and leading teams. Certified Case Manager (CCM) or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field. A minimum of 6 years' progressive leadership experience in Medi-Cal care management, transitions of care, or related clinical operations. A minimum of 10 years' combined experience managing projects, programs, complex change initiatives, and/or CMS, NCQA and DHCS audits and regulatory compliance Experience in care management and/or transitions of care services, at a health plan or similar health care organization structure Working knowledge or experience in utilization management at a health plan or similar healthcare organization structure, with the ability to support or lead integration efforts if future models include closer alignment between UM (concurrent review) and care management activities. 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 is a 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: o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
Your Role
The Director of Transitional Care Services reporting to the Sr Director, Population Health Management, will work to implement whole person integrated healthcare by leading Care Management for the MediCal member population. This role will provide leadership, direction, and oversight to our Medi-Cal Transitional Care Services team and ensure that our beneficiaries receive case management interventions and linkages to essential services while residing in an inpatient setting and post-discharge. Services will include linkage to PCPs and specialist and linkage to other supportive services such as CalAIM Enhanced Care Management, CalAIM Community Supports, the Community Health Worker Benefit and Long-Term Services and Supports. This leader will support the Population Health program designed to engage members, reduce disparities and gaps in care, and improve quality for our Medi-Cal members. This position will drive member experience and engagement, improvement in the overall health of Blue Shield of California members, and affordability and efficiency. The Director contributes to the overall strategy and goals of the Medical Care Solutions organization. This role is being created in compliance with the MediCal mandate requirement outlined by the Cal-AIM Population Health Management program.
Responsibilities
Your Work
In this role, you will: Be accountable for annual strategic planning, resource planning to ensure appropriate resources are allocated to projects and are appropriately calculated in the PHM transitional care services department budget Act as a change agent for Population Health Management to improve performance results, provides organizational effectiveness leadership to achieve department goals (people/process/technology), with a focus on optimizing Transitional Be responsible for the care management team that focuses on high quality patient care and other high member touch programs within Medi-Cal line of business, with TCS integrated as a core function to support timeless coordination during inpatient stays and post-discharge outreach. Establish strong partnerships across the organization including Utilization Management, Human Resources, Planning & Finance, Control Tower, Program Delivery (Project Management Office) and IT. Coordinate PHM transitional care services team readiness for new benefits implementations with the goal of ensuring all members have access to the right care, at the right time, and at the right benefit at the right price on their effective date and all operational metrics are within agreed upon service levels. Develop and maintain a training and learning development plan Ensure ongoing business process management using continuous process improvement practices, and implementation of technology to drive greater efficiency, productivity and customer experience Ensure a culture of affordability, drives leadership principles among people managers, and ensures team actions are in place to make Blue Shield a great place to work Responsible for driving the strategic outcome of the Medi-Cal line of business for PHM Transitional Care Services. This includes the evaluation of data from multiple sources, designing and refining care coordination programs in conjunction with other clinical leaders, and reviewing key performance indicators to inform ongoing program improvement, staffing alignment, and member engagement strategies. Responsible for partnering with MediCal leadership and other market leadership to design, develop and implement key initiatives that will enhance the value and performance of the Medi-Cal product by developing products, services, processes or systems that are new to Blue Shield. This includes identifying opportunities within PHM Transitional Care Services to pilot or scale approaches that improved care coordination, member outcomes, and operational efficiency. Responsible for key PHM Transitional Care Services metrics related to compliance and contractual obligations by ensuring teams are within compliance in accordance with all regulations and contractual obligations. Develop prospective approach to maintaining audit readiness, maintaining documentation, workflows, and reporting practices that demonstrate consistent compliance and program integrity. Serve as a representative of PHM Transitional Care Services department for areas of responsibility. Lead as a subject matter expert in all regulatory requirements and operational processes related to Medi-Cal care management, with a focus on transitions of care and coordination across settings. Maintain staffing and development of PHM Transitional Care Services clinical and non-clinical staff. Works with Medi-Cal leadership and market leaders to ensure appropriate staffing ratios based on future processes and regulations. Be able to forecast staffing levels within budgetary guidelines as appropriate. Work cross functionally to start new Care Management initiatives, including those aimed at impacting on the total cost of care. Lead the identification and operationalization of initiatives across PHM and Transitional Care Services, ensuring alignment with enterprise goals. Review results from key performance indicators and adjust accordingly. Lead or participate directly in the establishment of long term functional or regional strategies in support of Blue Shield's long term business strategy Occasional business travel required. Population Health Management team members are located at four Blue Shield sites in California Qualifications
Your Knowledge and Experience
College degree or equivalent experience required. Advanced degree commensurate with field preferred. Must maintain active, unrestricted CA RN license or current LCSW, LMFT, LPCC, or PsyD by the Board of Behavioral Health Sciences A minimum of 6 years' experience successfully managing people and leading teams. Certified Case Manager (CCM) or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field. A minimum of 6 years' progressive leadership experience in Medi-Cal care management, transitions of care, or related clinical operations. A minimum of 10 years' combined experience managing projects, programs, complex change initiatives, and/or CMS, NCQA and DHCS audits and regulatory compliance Experience in care management and/or transitions of care services, at a health plan or similar health care organization structure Working knowledge or experience in utilization management at a health plan or similar healthcare organization structure, with the ability to support or lead integration efforts if future models include closer alignment between UM (concurrent review) and care management activities. 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 is a 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: o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.