Director of Medicare and Medi-Cal Utilization Management
1 day ago
The Director of Medicare and Medi-Cal Utilization Management will play a critical role in the success of Blue Shield of California and the Utilization Management department in realizing its goals and objectives.
Key Responsibilities- Develop and implement utilization management strategies to ensure timely and cost-effective care for patients.
- Lead the development of operational metrics and productivity analysis to support workforce planning and rationalization of services.
- Partner with physicians and other stakeholders to improve utilization of effective and appropriate services.
- Establish and measure productivity metrics to support workforce planning and rationalization of services.
- Review and report on utilization review trends for Medicare and Medi-Cal membership.
- Ensure alignment of authorization strategies with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.
- Manage strategic projects and support operations initiatives.
- Lead operational implementation of transformation changes, including organizational management, process implementation, and technology adoption.
- Responsible for operational teams' performance, resource management, continuous improvement, and training.
- Ensure operational processes meet regulatory and accreditation requirements.
- Foster a culture of process excellence, BSC leadership principles, and a great place to work environment.
- Current CA RN License
- Bachelor's of Science in Nursing or advanced degree preferred
- Master's degree or equivalent experience preferred
- Minimum of 10 years of Utilization Management or relevant experience, including 6 years of management experience
- Minimum of 5 years of progressive leadership in Utilization Management operations
- Health plan or similar health care organization structure experience required
- Successful track record in driving organizational change management
- Excellent relationship and consensus-building skills required
Blue Shield of California offers a competitive salary range of $ to $ for this role in California.
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Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleWe are seeking a highly experienced and skilled Director, Medicare & Medi-Cal Utilization Management to join our team at Blue Shield of California. This critical role will play a key part in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal membership.Key...
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