Director, Medi-Cal/Medicare Utilization Management Nurse Management

Location: El Dorado Hills
Posted on: June 23, 2025

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 Bachelor’s of Science in Nursing or advanced degree preferred Master’s 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

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