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Director Utilization Management

Blue Cross Blue Shield of Kansas

Topeka, Kansas

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JOB DETAILS
SKILLS
Access Authorization, Accreditation Standards, Behavioral Health, Budgeting, Clinical Practices/Protocols, Continuous Improvement, Cost Effectiveness Analysis, Cross-Functional, Customer Escalations, Dental Insurance, Federal Laws and Regulations, Financial Management, Financial Planning, Fitness, Healthcare Quality, Incentive Programs, Information/Data Security (InfoSec), Leadership, Medical Affairs, National Committee for Quality Assurance (NCQA), Operational Strategy, Performance Analysis, Performance Management, Performance Metrics, Performance Tuning/Optimization, Policy Development, Productivity Management, Quality Management, Regulatory Compliance, Regulatory Requirements, Return on Investment (ROI), State Laws and Regulations, Strategic Planning, Team Player, Time Management, Training Program, Training/Teaching, Utilization Management, Utilization Review Accreditation Commission (URAC), Vision Plan
LOCATION
Topeka, Kansas
POSTED
1 day ago
Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.

Why Join Us?
  • Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
  • FamilyComes First: Total rewards package that promotes the idea of family first for all employees. Paid vacation and sick leave with paid maternity and paternity available immediately upon hire
  • Professional Growth Opportunities: Advance your career with ongoing training and development programs.
  • Dynamic Work Environment: Collaborate with a team of passionate and driven individuals in a work environment that promotes flexibility.
  • Trust and Stability: Work for one of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.
  • Inclusive Work Environment: We pride ourselves on fostering a workplace where everyone is valued and respected.

Benefits & Perks
  • Base compensation is only one component of your competitive Total Rewards package
  • Incentive pay program (EPIP)
  • Health/Vision/Dental insurance
  • 6 weeks paid parental leave for new mothers and fathers
  • Fertility/Adoption assistance
  • 2 weeks paid caregiver leave
  • 401(k) plan matching up to 5%
  • Tuition reimbursement
  • Health & fitness benefits, discounts and resources

Job Summary

The Director of Utilization Management provides strategic and operational leadership for enterprise utilization management functions, including clinical review, clinical claims review, and prior authorization programs. This role is accountable for ensuring the delivery of high-quality, cost-effective care through evidence-based clinical decision-making, regulatory compliance, and performance optimization across these operations. The Director serves as a clinical subject matter expert supporting quality care management, population health, behavioral health integration, and clinical strategy initiatives, while driving cross-functional collaboration within Medical Affairs and across the enterprise to advance organizational goals, member outcomes, and value-based care priorities.

"This position is eligible to work hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment."

What you'll do
  • Provide strategic leadership and enterprise-wide operational oversight for utilization management programs across all lines of business, including prior authorization, concurrent and retrospective claims review, and appeals.
  • Ensure utilization management activities align with enterprise strategy, Medical Affairs objectives, evidence-based clinical guidelines, and accreditation standards (for example, National Committee For Quality Assurance and Utilization Review Accreditation Commission standards, as applicable), including accreditation readiness, and all applicable state and federal regulatory requirements, including compliance activities, audits, regulatory examinations, and adherence to confidentiality, information security, and corporate standards.
  • Lead transformation and modernization initiatives to reduce variation, eliminate redundancy, improve efficiency, and enhance member and provider experience by directing the design, implementation, standardization, and continuous improvement of utilization management policies, procedures, and clinical workflows.
  • Oversee day-to-day utilization management operations, including intake, triage, case routing, escalation processes, and timely, consistent execution of utilization management decisions.
  • Establish, monitor, and report utilization management performance metrics, including turnaround times, denial and appeal rates, quality outcomes, costs, and return on investment.
  • Collaborate with the rest of Medical Affairs, Quality, Population Health, Behavioral Health, and Care Management leaders to integrate utilization strategies that improve outcomes and support whole-person care.
  • Serve as a clinical subject matter expert for utilization management, advising senior leadership on clinical trend drivers and total cost of care opportunities.
  • Lead and develop multidisciplinary utilization management teams, including hiring, performance management, workforce productivity, and fostering a culture of accountability, engagement, and continuous improvement.
  • Manage utilization management financial planning and external partnerships, including operational budgeting, cost-effectiveness strategie

About the Company

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Blue Cross Blue Shield of Kansas