Your Role

Reporting to the Sr. Director, Utilization Management, the role of the Director, Medicare & Medi-Cal 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 the Utilization Management team in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal membership. The Director, Medicare & Medi-Cal 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 to support workforce planning methodology and rationalization of services required to perform UM reviews.
• Reviewing and reporting out on Utilization Review (UR) trending for Medicare and Medi-Cal 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.

Your Knowledge and Experience

• Requires 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: $ 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.

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