Director of Commercial Utilization Management

4 weeks ago


San Diego, California, United States Blue Shield of CA Full time
Your Role

As the Director of Commercial Utilization Management, you will play a critical role in the success of Blue Shield of California and the Utilization Management department in achieving its goals and objectives.

This position requires a seasoned leader who can collaborate with the Utilization Management team to deliver and implement all aspects of utilization management and care coordination for Commercial membership.

The Director will provide direction and leadership in compliance with regulatory requirements and key operational metrics.

Your Responsibilities
  1. Manage and monitor prior authorization and concurrent review to ensure timely and cost-effective care for patients.
  2. Develop and lead the implementation of UM strategy by leveraging data/analytics to inform technology solutions that streamline operational efficiencies.
  3. Provide analysis and reports of significant utilization trends, patterns, and resource allocation.
  4. Partner with physicians and others to develop improved utilization of effective and appropriate services.
  5. Establish and measure productivity metrics to support workforce planning methodology and rationalization of services required to perform UM reviews.
  6. Review and report on Utilization Review (UR) trending for Commercial membership.
  7. Ensure alignment of the authorization strategy with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.
  8. Manage strategic projects and support operations initiatives.
  9. Lead operational implementation of transformation changes (organizational management, process implementation, technology adoption).
  10. Oversee operational teams' performance, resource management, continuous improvement, and training.
  11. Ensure operational audit readiness, maintaining adequate processes and internal audit measures quarterly.
  12. Ensure all operational processes meet regulatory and accreditation requirements.
  13. Foster a culture of process excellence, BSC leadership principles, and a great place to work environment.
  14. Occasional business travel required.
Your Qualifications
  • Current CA RN License required.
  • Bachelor of Science in Nursing or advanced degree preferred.
  • Master's degree or equivalent experience preferred.
  • Minimum of 10 years prior relevant experience, including 6 years of management experience.
  • Minimum of 5 years of progressive leadership in Utilization Management operations preferred.
  • 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.
Pay Range

The pay range for this role is: $165,990.00 to $248,930.00 for California.

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade.

Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.



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