Blue Shield of California
Director, Medicare & Medi-Cal Utilization Management
Blue Shield of California, Rancho Cordova, California, us, 95741
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.
#LI-SS8
Director, Medicare & Medi-Cal Utilization Management at Blue Shield of California summary:The Director of Medicare & Medi-Cal Utilization Management plays a vital role in the success of Blue Shield of California by overseeing utilization management and care coordination for Medicare and Medi-Cal beneficiaries. This position involves managing prior authorization processes, developing UM strategies using data analytics, and ensuring compliance with regulatory requirements while fostering a culture of continuous improvement. The director also leads operational initiatives, implements strategic projects, and collaborates with clinical teams to enhance utilization of services and optimize the quality of care.
Keywords:Utilization Management, Medicare, Medi-Cal, Healthcare Leadership, Regulatory Compliance, Operational Efficiency, Data Analytics, Patient Care Coordination, Healthcare Management, Organizational Change
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.
#LI-SS8
Director, Medicare & Medi-Cal Utilization Management at Blue Shield of California summary:The Director of Medicare & Medi-Cal Utilization Management plays a vital role in the success of Blue Shield of California by overseeing utilization management and care coordination for Medicare and Medi-Cal beneficiaries. This position involves managing prior authorization processes, developing UM strategies using data analytics, and ensuring compliance with regulatory requirements while fostering a culture of continuous improvement. The director also leads operational initiatives, implements strategic projects, and collaborates with clinical teams to enhance utilization of services and optimize the quality of care.
Keywords:Utilization Management, Medicare, Medi-Cal, Healthcare Leadership, Regulatory Compliance, Operational Efficiency, Data Analytics, Patient Care Coordination, Healthcare Management, Organizational Change