Cvs Health Utilization Management Jobs in California

Your Role 

The Behavioral Health Utilization Management (UM) team performs prior authorization and concurrent reviews for members by applying evidenced based guidelines, policies, and nationally recognized clinical criteria across multiple lines of business. The Manager, Behavioral Health Utilization Management will report to the Sr. Manager, Behavioral Health Utilization Management. In this role you will be responsible for the day-to-day operations of the business unit and execution of departmental goals and objectives.

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.

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. 

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 Knowledge and Experience 

• Current, unrestricted CA LMFT, LCSW, LPCC, PhD/PsyD or RN license required

• Associates degree required for an RN license

• Master's degree in counseling required for LMFT, LCSW, LPCC

• Bachelor of Science in Nursing preferred

• Doctoral degree required for PhD or PsyD

• Requires advanced knowledge of job area usually obtained through advanced education combined with experience

• Requires at least seven (7) years of prior relevant experience 

• Three (3) years of management experience gained as a team leader, supervisor or project/program manager

• Three (3) years conducting Utilization Management for a health plan preferred 

• Understands Blue Shield of CA's mission and business plan 

• 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

• Strong understanding of behavioral health utilization management including application of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines 

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

Your Work 

In this role, you will: 

• Manage a team of licensed clinicians responsible for prior authorization and concurrent review 
• Be responsible for the daily operations of the Behavioral Health Utilization Management team including staffing, scheduled work, assignments, efficient workflow, and performance 
• Provide oversight of licensed clinicians to ensure appropriate application of clinical guidelines 
• Oversee caseload management and adherence to regulatory, accreditation and contractual requirements 
• Monitor clinician workloads via daily performance monitoring reports 
• Representing Behavioral Health UM as a Subject Matter Expert in cross departmental meetings and process design