Director, Medi-Cal/Medicare Utilization Management Nurse Management Position Available In Plymouth, Massachusetts

Job Description:

Your Role Reporting to the Sr. Director, Utilization Management,the role of the Director, Medicare & Medi-Cal UtilizationManagement is critical to the success of Blue Shield of Californiaand the Utilization Management department in realizing its goalsand objectives. This individual will play a key role as part of theUtilization Management team in delivering and collaborating on allaspects of utilization management and care coordination for ourMedicare and Medi-Cal membership. The Director, Medicare & Medi-CalUtilization Management role will also provide direction andleadership in compliance to regulatory requirements and keyoperational metrics. Your Work In this role, you will: Manages andmonitors prior authorization and concurrent review to ensure thatthe patient is getting the right care in a timely andcost-effective way. Leading development of UM strategy byleveraging the use of data/analytics to inform and technologysolutions to streamline operational efficiencies while alsobuilding a cost-benefit methodology to rationalize decisions on UMreviews to be performed based upon staffing costs, productivity,and projected medical cost savings. Provides analysis and reportsof significant utilization trends, patterns, and resourceallocation. Partners with physicians and others to develop improvedutilization of effective and appropriate services. Establishing andmeasuring productivity metrics to support workforce planningmethodology and rationalization of services required to perform UMreviews. Reviewing and reporting out on Utilization Review (UR)trending for Medicare and Medi-Cal membership. Ensuring alignmentof the authorization strategy with clinical policy, paymentintegrity, and network development strategies to optimize qualityand cost of care. Responsible for managing strategic projects andsupporting operations initiatives. Leading operationalimplementation of transformation changes (organizationalmanagement, process implementation, technology adoption).Responsible for operational teams’ performance, resourcemanagement, continuous improvement, and training. Responsible foroperational audit readiness, ensuring adequate processes andinternal audit measures in place and maintained quarterly. Ensuringall operational processes are meeting regulatory and accreditationrequirements. Fosters a culture of process excellence, BSCleadership principles, and a great place to work environment.

Occasional business travel required. Your Knowledge and ExperienceRequires current CA RN License Bachelor’s of Science in Nursing oradvanced degree preferred Master’s degree or equivalent experiencepreferred Minimum of 10 years of Utilization Management or relevantexperience, including 6 years of management experience Minimum of 5years of progressive leadership in Utilization Managementoperations Health plan or similar health care organizationstructure experience required Successful track record in drivingorganizational change management Excellent relationship andconsensus-building skills required