Director, Commercial Utilization Management

Your Role

Reporting to the Sr. Director, Utilization Management, the role of the Director, Commercial Utilization Management is critical to the success of Blue Shield of California and the Utilization Management department in realizing its goals and objectives. This individual will play a key role as part of Utilization Management team in delivering and collaborating on all aspects of utilization management and care coordination for Commercial membership. The Director, Commercial Utilization Management role will also provide direction and leadership in compliance to regulatory requirements and key operational metrics.

Your Work

In this role, you will:

1. Manage and monitor prior authorization and concurrent review to ensure that the patient is getting the right care in a timely and cost-effective way.
2. Lead development of UM strategy by leveraging the use of data/analytics to inform and technology solutions to streamline operational efficiencies while also building a cost-benefit methodology to rationalize decisions on UM reviews based upon staffing costs, productivity, and projected medical cost savings.
3. Provide analysis and reports of significant utilization trends, patterns, and resource allocation. Partner with physicians and others to develop improved utilization of effective and appropriate services.
4. Establish and measure productivity metrics in order to support workforce planning methodology and rationalization of services required to perform UM reviews.
5. Review and report on Utilization Review (UR) trending for Commercial membership.
6. Ensure alignment of the authorization strategy with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.
7. Manage strategic projects and support operations initiatives.
8. Lead operational implementation of transformation changes (organizational management, process implementation, technology adoption).
9. Oversee operational teams' performance, resource management, continuous improvement, and training.
10. Ensure operational audit readiness, maintaining adequate processes and internal audit measures quarterly.
11. Ensure all operational processes are meeting regulatory and accreditation requirements.
12. Foster a culture of process excellence, BSC leadership principles, and a great place to work environment.
13. Occasional business travel required.

Your Knowledge and Experience

1. Requires current CA RN License.
2. Bachelor of Science in Nursing or advanced degree preferred.
3. Master's degree or equivalent experience preferred.
4. Minimum of 10 years prior relevant experience, including 6 years of management experience.
5. Minimum of 5 years of progressive leadership in Utilization Management operations preferred.
6. Health plan or similar health care organization structure experience required.
7. Successful track record in driving organizational change management.
8. Excellent relationship and consensus-building skills required.

Pay Range: $165,990.00 to $248,930.00 for California.

Note: 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.