Director, Medicare and Medi-Cal Utilization Management
1 week ago
As a key member of the Utilization Management team at Blue Shield of California, the Director, Medicare & Medi-Cal Utilization Management plays a critical role in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal membership.
This individual will lead the development of UM strategy by leveraging data/analytics to inform and technology solutions to streamline operational efficiencies while also building a cost-benefit methodology to rationalize decisions on UM reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.
The Director, Medicare & Medi-Cal Utilization Management will also provide direction and leadership in compliance to regulatory requirements and key operational metrics.
Your Responsibilities
Manages and monitors prior authorization and concurrent review to ensure that the patient is getting the right care in a timely and cost-effective way.
Develops and implements UM strategy by leveraging data/analytics to inform and technology solutions to streamline operational efficiencies while also building a cost-benefit methodology to rationalize decisions on UM reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.
Provides analysis and reports of significant utilization trends, patterns, and resource allocation. Partners with physicians and others to develop improved utilization of effective and appropriate services.
Establishes and measures productivity metrics to support workforce planning methodology and rationalization of services required to perform UM reviews.
Reviews and reports out on Utilization Review (UR) trending for Medicare and Medi-Cal membership.
Ensures alignment of the authorization strategy with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.
Responsible for managing strategic projects and supporting operations initiatives.
Leads operational implementation of transformation changes (organizational management, process implementation, technology adoption).
Responsible for operational teams' performance, resource management, continuous improvement, and training.
Responsible for operational audit readiness, ensuring adequate processes and internal audit measures in place and maintained quarterly.
Ensures all operational processes are meeting regulatory and accreditation requirements.
Fosters a culture of process excellence, BSC leadership principles, and a great place to work environment.
Occasional business travel required.
Requirements
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
Pay Range:
The pay range for this role is: $ to $ for California.
Note:
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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