Director, Commercial Utilization Management
: Job Details :


Director, Commercial Utilization Management

Blue Shield of California

Location: Rancho Cordova,CA, USA

Date: 2024-11-12T01:19:28Z

Job Description:
Job DescriptionYour 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:
  • 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.
  • Leading 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 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.
  • Establishing and measuring productivity metrics in order to support workforce planning methodology and rationalization of services required to perform UM reviews.
  • Reviewing and reporting out on Utilization Review (UR) trending for Commercial membership.
  • Ensuring 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.
  • Leading 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.
  • Ensuring 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.
QualificationsYour Knowledge and Experience
  • Requires current CA RN License
  • Bachelors 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: $ 165990.00 to $ 248930.00 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. #LI-SS8 About the Team Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen. Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us! Our Values:
  • Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
  • Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
  • Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model: Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work. Two ways of working: Hybrid (our default) and office
  • Hybrid - In a business unit approved office a few times per year to 3 days per week, on average
  • Office - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an Essential Role, the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail. Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
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