Director, Medicare & Medi-Cal Utilization Management
Company: Hispanic Technology Executive Council
Location: Rancho Cordova
Posted on: October 17, 2024
Job Description:
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
- Bachelors of Science in Nursing or advanced degree
preferred
- Masters 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
Keywords: Hispanic Technology Executive Council, North Highlands , Director, Medicare & Medi-Cal Utilization Management, Executive , Rancho Cordova, California
Didn't find what you're looking for? Search again!
Loading more jobs...