Utilization Management Jobs in Edina, MN (NOW HIRING)

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.

The Impact You Will Have

The Director of Utilization Management leads and directs the utilization review staff is responsible for ensuring policies and procedures incorporate best practices and ensure efficient and effective utilization reviews. They manage and monitor prior authorizations and concurrent reviews through the clinical appeals process to ensure that the member is getting the right care in a timely and cost-effective way. They also manage retrospective reviews after treatment has been completed, which includes oversight of the clinical payment integrity team. They partner with the UM Product Manager to identify significant utilization trends, patterns, and provider behavior. The incumbent adapts operations as needed to drive value in line with the product roadmap. They consult and collaborate with internal and external teams to gain alignment and improved utilization of effective and appropriate services. The director ensures that business objectives are aligned to the product strategy, holds associates accountable to efficiency and productivity standards that ensure financial, compliance and quality objectives are met.

Your Responsibilities

• Provide strategic direction, leadership, and operations oversight to programs and staff to optimize efficiency and effectiveness of Utilization Management operations, deliver positive health outcomes, meet/exceed performance guarantees and increase stakeholder satisfaction.
• Collaborate with strategic partners and external customers to innovate, design and deliver operational rigor that supports the utilization management product strategy and delivers value to customers in alignment with corporate and divisional priorities.
• Direct operational readiness and regulatory/accreditation compliance via formal processes such as policy and procedure, program descriptions, auditing, training, and metric monitoring and management.
• Lead the evaluation of operational performance based on performance against industry benchmarks and acts on opportunities to enhance and improve.
• Direct the creation, prioritization, and execution of approved business cases. Lead the creation and communication of program performance value through formal and informal presentations, dashboards, RFP content, client meetings and committee participation.
• Serves as a change leader supporting, communicating and taking personal ownership of operational strategy and success criteria.
• Leverage vendor partners and build a network among external market influencers, including regulatory bodies and Blue Plan resources, to bring new ideas and solutions that increase the value delivered to all stakeholders and to communicate existing value to the market.
• Constantly scans the market for tools and technology that will improve operational efficiency and quality. Champions adoption and implementation of those tools that will drive business value.
• Partners with workforce management to drive toward standardized metrics to measure productivity and quality. Establishes process to continually monitor teams' progress against established standards and holds staff accountable to meeting standards.
• Create and foster an environment where Medical Management staff can work effectively and efficiently at the top of their licensure.
• Leads and directs a high performing team including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive the proper training. Conducts performance evaluation and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations and cost control.
• With the UM Product Manager, is accountable for the delivery of utilization management Affordability of Care (AOC) targets

Required Skills and Experience

• 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.
• Demonstrated maturity, flexibility and capacity to navigate a complex structure with strong critical thinking, problem solving/conflict resolution skills.
• Superior facilitation, written and oral communications skills to convey complex ideas simply, through written reports and presentation materials.
• Strong leadership skills with the ability to generate ideas, support and commitment from constituents.
• Demonstrated team building, mentoring and coaching skills with experience leading professional staff.
• Strong business acumen and understanding of cross-industry business practices, market and competitive drivers.
• Demonstrated ability to drive and execute results in a complex cross functional environment.
• Demonstrated knowledge of healthcare payer industry and business processes.
• Ability to see across the enterprise and identify potential risks and issues that impact other ongoing work efforts.
• Strong teamwork and interpersonal skills at all levels.
• Must be able to work effectively with cross functional groups, fostering teamwork with a commitment to quality.
• Demonstrated ability to understand business strategy, including deep expertise with the accountability of scope and relate that strategy to program execution business knowledge across multiple functional areas.
• Strategic thinking and critical decision making at an enterprise level.
• Ability to thrive in ambiguity and adapt approach as needed.
• High school diploma (or equivalency) and legal authorization to work in the U.S.

Preferred Skills and Experience

• Advanced degree in business, finance or healthcare administration
• Health plan program leadership experience
• Current MN state licensure without restriction (i.e., RN or licensed independent mental health practitioner preferred)

Anchored in Connection

Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week - most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships, creativity, and alignment. The rest of the week you are empowered to work remote.

Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical, dental, and vision insurance

• Life insurance

• 401k

• Paid Time Off (PTO)

• Volunteer Paid Time Off (VPTO)

• And more

To discover more about what we have to offer, please review our benefits page.

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affirmative Action plan, as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to, and will not be discriminated against based on any legally protected characteristic.

Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: talent.acquisition@bluecrossmn.com.

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