Blue Cross and Blue Shield of Minnesota hiring Senior Director - Utilization Management in Eagan, Minnesota, United States | LinkedIn (2024)

About Blue CrossBlue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We’re committed to reinventing health care to improve health for our members and the community. We hope you'll join us.

How Is This Role Important to Our Work?

This position is responsible for the design, strategic planning, development, implementation, and administration of all aspects of the utilization management programs and medical policies for all lines of business. The scope of utilization management is inclusive of medical conditions and behavioral health that may be administered internally or externally. The position is accountable for delivering a high value (both clinical and financial) utilization management program to BCBSMN customers and for assuring members receive high quality and appropriate clinical care in a timely and cost-effective manner.

This position will also collaborate closely with the Provider Network leadership and the leadership of Commercial and Government markets to meet the unique health needs of their specific member populations and to position BCBSM as a leader in utilization management.

A Day In The Life

• Administers and manages utilization management programs in partnership with the VP of Behavioral Health, Senior Medical Director of Medical Management, Senior Medical Director of Behavioral Health and the Senior Director of Case Management, as well as other key internal stakeholders.
• Establishes department goals and performance metrics that support the division and enterprise strategic plans. Ensures that the right systems, processes, and measurement/reporting are in place to demonstrate the value and clinical effectiveness of utilization management programs to customers.
• Incorporates the use of evidence-based practice and appreciative enquiry into program development and improvement activities.
• Manages relationships and operations with external partners that provide utilization management services for BCBS MN.
• Enhances operational efficiency to optimize and maximize staff and external partner productivity and value.
• Educates internal staff and contracted providers on the general and unique health needs of populations being served, emphasizing adherence to BCBSMNs benefits, medical, and reimbursem*nt policies.
• Supports enterprise initiatives to enhance the member experience, reduce health disparities, advance the Affordability of Care and improve clinical quality.
• Oversees medical necessity and appropriateness reviews, application of contract benefits and quality of care decisions as appropriate in partnership with Senior Medical Director.
• Represents BCBS to a variety of external stakeholders including provider organizations, customers, advocacy groups and government entities as needed.
• Participates in community health forums as needed. Meets applicable regulatory and compliance standards and accreditation requirements by maintaining a continuous quality improvement program to support external and internal audits.

Staff Development

• Establishes rigorous performance measurement and improvement to ensure that business processes are efficient, staff is optimally deployed, and programs achieve their intended outcomes and customer commitments.
• Ensures talent is in place to improve member health.
• Serves as a role model and coach for ongoing leadership and staff development.
• Enhances teamwork and collaboration across the enterprise.

Nice to Have

• Post graduate education in Health Care Administration, Public Health, or an MBA.
• Active applicable Minnesota (medical doctor or nursing) licenses without restrictions.

Required Skills & Experiences

• Accepting this position at BCBSMN requires signing an Employee Confidentiality, Intellectual Property Assignment, and Restrictive Covenants Agreement as a condition of employment.
• 7+ years of related professional experience, with 3+ years of management experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
• 5+ years of clinical/care delivery experience.
• 5+ years in a care management leadership position in a health plan or health care delivery system serving customers, members, or patients.
• Ability to establish strategic direction for care management.
• Ability to drive operational execution and consistently deliver business results.
• Demonstrated ability to lead people, create high performing teams and develop talent.
• Ability to organize and manage multiple priorities and budgets.
• Excellent communication and presentation skills.
• Ability to support sales
• Excellent relationship skills to partner on shared goals with other Blue Cross teams and colleagues as well as with external key influencers.
• Seasoned clinical judgment, root cause analysis and conflict resolution skills.
• Proficiency with data and analysis used to monitor case, disease and utilization management, clinical quality and operations management.
• Demonstrated ability to work with other leaders to create solutions that meet the unique needs of their segments and customers.
• Candidates must possess high ethical standards and share the organization's commitment to key values.
• Proficiency with Microsoft Office suite of programs.
• Able to travel 10 to 20%.

Make A DifferenceBlue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic.

Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talent.acquisition@bluecrossmn.com.

All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.