Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in – join us!
Your Role
Reporting to the Sr. Director, Utilization Management, the role of the Director, Utilization Management (CalPERS) 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 Utilization Management team in delivering and collaborating on all aspects of utilization management and care coordination for CalPERS membership. The Director, Utilization Management (CalPERS) 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 in order to support workforce planning methodology and rationalization of services required to perform UM reviews.
- Reviewing and reporting out on Utilization Review (UR) trending for CalPers 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.
- Master’s degree or equivalent experience preferred.
- Minimum of 10 years prior relevant experience, including 6 years of management experience.
- Minimum of 5 years of progressive leadership in Utilization Management operations, preferred.
- In-depth knowledge of Blue Shield of California’s mission, vision, and strategy, and healthcare industry environment.
- Requires broad management knowledge to lead project teams in one department/function or large centralized function.
- Requires mastery level knowledge and skills within a specific technical or professional discipline with broad understanding of other areas within the job function.
- Requires business acumen, strategic thinking, financial analytical skills and decision-making skills.
Our Values
Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
