Utilization Management Clinical EducatorThe Enterprise Learning team is responsible for all new hire and existing staff technical and clinical education for multiple departments within Medical Care Solutions and Health Care Quality and Affordability. This includes Utilization Management, Case Management, Population Health Management, Post Service, and Appeals & Grievances. The Utilization Management Clinical Educator position will report to the Senior Stakeholder Manager in Enterprise Learning. In this role you will be supporting the following: Clinical education programs for new and existing staff supporting Utilization Management. Partner with Utilization Management operational departments to develop clinical training modules for Utilization Management clinical reviews for all lines of business.ResponsibilitiesIn this role, you will:Manage and facilitate formal clinical education for new hires and existing clinical staff for Utilization ManagementConduct Utilization Management clinical education on multiple inpatient and outpatient medical necessity case scenariosClinical education on Utilization Management clinical criteria for all lines of business (Medicare, Medi-Cal, FEP, Commercial, etc.)Develop and design training modules for clinical education for Utilization Management using clinical expertise and medical necessity criteriaClinical new hire and continuing education on Utilization Management department processes and workflowsCreate learning competencies and assessments for Utilization Management education programSupport Utilization Management learning projects for Blue Shield of CaliforniaAct as a liaison and provide support and resources to Utilization Management medical directors and cliniciansPartner will the quality and documentation teams to address quality trends or compliance issues and ensure documentation is precise and easy to followAttend clinical conferences and educational webinars on Utilization Management clinical criteria and educationSupport education on regulatory mandates for Utilization ManagementUse the ADDIE model to support Utilization Management projectsUse Kirkpatrick model to evaluate Utilization Management learning effectivenessQualificationsYour Knowledge and Experience:Bachelor's degree or equivalent experience, requiredCurrent and unrestricted California RN license, requiredMinimum 7 years of prior relevant clinical experience, requiredExperience working in an acute care clinical setting, preferredExperience working for a Health Payer in Utilization Management, preferredKnowledge of MCG guidelines, medical policies, and Utilization Management clinical criteria, preferredKnowledge of regulatory agencies DMHC, NCQA, CMA, and DHCS regulatory agencies, preferredExperience educating and training clinicians, preferredExperience developing clinical training programs, preferredExperience with navigating multiple systems/resources simultaneouslyAbout UsAbout Blue Shield of CaliforniaAs 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 ModelWe believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:For most teams, this means coming into the office two days per week.Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.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.The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.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 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.