Director Utilization Management

Director Utilization Management Blue Cross and Blue Shield of Kansas - 3.9 Topeka, KS Job Details Full-time 15 hours ago Benefits Paid parental leave Caregiver leave Health insurance Dental insurance Tuition reimbursement Adoption assistance Parental leave Vision insurance 401(k) matching Gym membership Qualifications Appeals Stakeholder engagement Program design Program management Phone communication Managed care organization experience CMS Leadership development High school diploma or GED Change management Information security compliance Team development CMS regulatory compliance Case appeal in utilization management Evidence-based practice Pre-authorization review for utilization management Medicare regulations Clinical program data analysis Resource utilization in healthcare Healthcare team management Business planning Clinical team leadership Healthcare policy implementation Operational excellence initiatives Cross-functional collaboration Insurance claims appeal handling Healthcare performance metrics analysis Cross-functional team management Data-driven decision making Cross-functional communication Full Job Description Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas. Why Join Us? Make a

Positive Impact:

Your work will directly contribute to the health and well-being of Kansans.

Family Comes First :

Total rewards package that promotes the idea of family first for all employees. Paid vacation and sick leave with paid maternity and paternity available immediately upon hire

Professional Growth Opportunities:

Advance your career with ongoing training and development programs.

Dynamic Work Environment:

Collaborate with a team of passionate and driven individuals in a work environment that promotes flexibility.

Trust and Stability:

Work for one of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.

Inclusive Work Environment:

We pride ourselves on fostering a workplace where everyone is valued and respected. Benefits & Perks Base compensation is only one component of your competitive Total Rewards package Incentive pay program (EPIP) Health/Vision/Dental insurance 6 weeks paid parental leave for new mothers and fathers Fertility/Adoption assistance 2 weeks paid caregiver leave 401(k) plan matching up to 5% Tuition reimbursement Health & fitness benefits, discounts and resources Job Summary The Director of Utilization Management provides strategic and operational leadership for enterprise utilization management functions, including clinical review, clinical claims review, and prior authorization programs. This role is accountable for ensuring the delivery of high-quality, cost-effective care through evidence-based clinical decision-making, regulatory compliance, and performance optimization across these operations. The Director serves as a clinical subject matter expert supporting quality care management, population health, behavioral health integration, and clinical strategy initiatives, while driving cross-functional collaboration within Medical Affairs and across the enterprise to advance organizational goals, member outcomes, and value-based care priorities. "This position is eligible to work hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment." What you'll do Provide strategic leadership and enterprise-wide operational oversight for utilization management programs across all lines of business, including prior authorization, concurrent and retrospective claims review, and appeals. Ensure utilization management activities align with enterprise strategy, Medical Affairs objectives, evidence-based clinical guidelines, and accreditation standards (for example, National Committee For Quality Assurance and Utilization Review Accreditation Commission standards, as applicable), including accreditation readiness, and all applicable state and federal regulatory requirements, including compliance activities, audits, regulatory examinations, and adherence to confidentiality, information security, and corporate standards. Lead transformation and modernization initiatives to reduce variation, eliminate redundancy, improve efficiency, and enhance member and provider experience by directing the design, implementation, standardization, and continuous improvement of utilization management policies, procedures, and clinical workflows. Oversee day-to-day utilization management operations, including intake, triage, case routing, escalation processes, and timely, consistent execution of utilization management decisions. Establish, monitor, and report utilization management performance metrics, including turnaround times, denial and appeal rates, quality outcomes, costs, and return on investment. Collaborate with the rest of Medical Affairs, Quality, Population Health, Behavioral Health, and Care Management leaders to integrate utilization strategies that improve outcomes and support whole-person care. Serve as a clinical subject matter expert for utilization management, advising senior leadership on clinical trend drivers and total cost of care opportunities. Lead and develop multidisciplinary utilization management teams, including hiring, performance management, workforce productivity, and fostering a culture of accountability, engagement, and continuous improvement. Manage utilization management financial planning and external partnerships, including operational budgeting, cost-effectiveness strategies, vendor and delegated entity oversight, and executive-level reporting. What you need

Knowledge/Skills/Abilities:

Advanced expertise in utilization management principles and workflows, including medical necessity determinations, prior authorization, concurrent and retrospective review, appeals, and denials management, with the ability to standardize and optimize processes to improve efficiency, consistency, and regulatory adherence. Deep understanding of managed care, payer operations, healthcare delivery systems, and health benefit plan design, including utilization drivers, cost containment, and value‑based care models. Proven success designing, implementing, and scaling utilization management programs aligned with organizational strategy, quality outcomes, and financial stewardship with demonstrated ability to apply evidence‑based clinical guidelines, medical policy, and coverage determinations to support consistent, compliant utilization and medical review decisions. Knowledge of regulatory, accreditation, and compliance requirements, including state and federal regulations, Centers for Medicare and Medicaid Services requirements, and corporate compliance standards. Strong analytical capability with experience translating utilization, clinical, and cost data into actionable operational insights and continuous quality improvement initiatives. Demonstrated leadership and change management experience, including leading multidisciplinary clinical and non‑clinical teams and developing people leaders. Strong cross‑functional collaboration and stakeholder influence, partnering effectively with Medical Directors and senior leaders while respecting clinical authority. Excellent written and verbal communication skills, with the ability to convey complex utilization concepts and data to diverse audiences, including executive leadership. High level of professional judgment, accountability, and discretion, with a strong commitment to quality, confidentiality, and best practices in utilization management.

Education and Experience:

High school diploma or equivalent required. Bachelor's degree in nursing, healthcare administration, public health, or related healthcare field preferred. In lieu of degree an additional 3 years' relevant experience required. Minimum of 8 years of progressive healthcare experience, including utilization management, care management, or clinical operations, with a strong working knowledge of the design and execution of utilization management strategies that reduce total cost of care while improving quality outcomes and patient and provider experience, required. Registered Nurse license and/or clinical licensure in the state of practice preferred. Minimum of 5 years of experience providing leadership for teams required.

Physical Requirements:

Prolonged periods of sitting at a desk and working on a computer Ability to communicate effectively in person, by phone, and electronically Ability to travel occasionally for meetings, conferences, or vendor site visits, as required Occasional standing, walking, bending, or reaching within the office environment May require occasional lifting of office materials or files (typically up to 10-15 pounds) Work is typically performed in an office environment with standard lighting and climate control Our Commitment to Connection and Belonging At Blue Cross and Blue Shield of Kansas, we are committed to fostering a culture of connection and belonging, where mutual respect is at the foundation of our workplace. We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law. Blue Cross and Blue Shield of Kansas conducts pre-employment drug screening, criminal conviction check, employment verifications and education as part of a conditional offer of employment.