Manager, Delegation Oversight

Blue Shield of California•Long Beach, CA

1d•Hybrid

About The Position

Your Role The Delegation Oversight team is responsible for driving continuous quality improvement across delegated functions and ensuring compliance with applicable regulatory, contractual, and accreditation requirements. The team oversees delegated Utilization Management (UM) activities in accordance with CMS, DMHC, DHCS, NCQA, and Blue Shield of California standards, as well as delegation requirements outlined in executed delegation agreements. 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 In this role, you will: Manage and oversee delegated Utilization Management functions to assess compliance with contractual, regulatory, and accreditation requirements. Lead efforts to identify risks, address deficiencies in delegation performance, implement corrective actions, and follow up to ensure timely and effective resolution. Implement recommendations for quality improvement and ensure corrective action plans are developed, monitored, and sustained. Interpret statistical and performance data to plan and implement actions that improve delegated utilization management outcomes. Identify areas for process improvement within both the organization and delegated entities, implementing solutions to enhance efficiency, quality of care, and regulatory compliance. Serve as a liaison between the organization and delegated entities, fostering clear communication and collaborative problem‑solving. Respond to questions from Medical Groups/IPAs and provide guidance related to delegation oversight, regulatory requirements, and UM expectations. Work closely with senior management, physicians, and clinical teams to provide updates on delegation performance, issues, risks, and resolutions. Collaborate with internal business partners supporting Medical Groups/IPAs to ensure alignment and effective oversight. Design and implement tools, training materials, and resources that comply with regulatory, legislative, and Blue Shield‑mandated requirements. Design work plans and workflows to support audit activities, quality initiatives, and ongoing delegation oversight. Oversee updates to audit tools to ensure alignment with current regulatory guidelines and industry best practices. Develop, review, and update delegation oversight policies and procedures to ensure alignment with regulatory changes and organizational goals.

Requirements

Bachelor of Science in nursing or advanced degree preferred
Current, unrestricted CA RN license required
7 years prior relevant experience, including 3 years of management experience gained as a team leader, supervisor or project/program manager.
In‑depth knowledge of state, federal, and accreditation standards, including CMS, NCQA, DHCS, and DMHC strongly preferred.
Advanced skills in business acumen, financial analysis, risk management, delegation oversight, and operational leadership
Experience supporting or participating in regulatory or accreditation audits preferred
Advanced knowledge of Utilization Management, delegation oversight, and healthcare regulatory requirements.
Demonstrated ability to lead and manage teams, processes, and projects within a regulated healthcare environment.
Strong analytical, critical thinking, and decision‑making skills, including the ability to interpret performance metrics and identify risk.
Strong verbal, written, and interpersonal communication skills, including communication with internal and external stakeholders.
Functional expertise within area of responsibility and recognition as a subject matter expert.
Understanding of Blue Shield of California’s mission, business plan, and healthcare industry environment.

Responsibilities

Manage and oversee delegated Utilization Management functions to assess compliance with contractual, regulatory, and accreditation requirements.
Lead efforts to identify risks, address deficiencies in delegation performance, implement corrective actions, and follow up to ensure timely and effective resolution.
Implement recommendations for quality improvement and ensure corrective action plans are developed, monitored, and sustained.
Interpret statistical and performance data to plan and implement actions that improve delegated utilization management outcomes.
Identify areas for process improvement within both the organization and delegated entities, implementing solutions to enhance efficiency, quality of care, and regulatory compliance.
Serve as a liaison between the organization and delegated entities, fostering clear communication and collaborative problem‑solving.
Respond to questions from Medical Groups/IPAs and provide guidance related to delegation oversight, regulatory requirements, and UM expectations.
Work closely with senior management, physicians, and clinical teams to provide updates on delegation performance, issues, risks, and resolutions.
Collaborate with internal business partners supporting Medical Groups/IPAs to ensure alignment and effective oversight.
Design and implement tools, training materials, and resources that comply with regulatory, legislative, and Blue Shield‑mandated requirements.
Design work plans and workflows to support audit activities, quality initiatives, and ongoing delegation oversight.
Oversee updates to audit tools to ensure alignment with current regulatory guidelines and industry best practices.
Develop, review, and update delegation oversight policies and procedures to ensure alignment with regulatory changes and organizational goals.