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Commercial Utilization Management Director
2 months ago
As a key member of the Utilization Management team at Blue Shield of California, the Director, Commercial Utilization Management plays a critical role in driving the success of the organization. This individual will be responsible for leading the development and implementation of utilization management strategies, ensuring alignment with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.
Key Responsibilities- Strategic Leadership: Develop and implement utilization management strategies to ensure timely and cost-effective delivery of care.
- Operational Excellence: Manage and monitor prior authorization and concurrent review processes to ensure optimal resource allocation and productivity.
- Analytics and Reporting: Provide analysis and reports on significant utilization trends, patterns, and resource allocation to inform business decisions.
- Project Management: Lead strategic projects and support operations initiatives to drive business growth and improvement.
- Team Management: Responsible for operational teams' performance, resource management, continuous improvement, and training.
- Audit and Compliance: Ensure operational processes meet regulatory and accreditation requirements, and maintain audit readiness.
- Culture and Leadership: Foster a culture of process excellence, BSC leadership principles, and a great place to work environment.
- Education: Bachelors of Science in Nursing or advanced degree preferred.
- Experience: Minimum of 10 years prior relevant experience, including 6 years of management experience.
- Leadership: Minimum of 5 years of progressive leadership in Utilization Management operations, preferred.
- Healthcare Experience: Health plan or similar healthcare organization structure experience required.
- Skills: Excellent relationship and consensus-building skills required.
