Director Clinical Operations - Utilization Management

Blue Cross Blue Shield of Minnesota•Eagan, MN

5d•Hybrid

About The Position

Blue Cross and Blue Shield of Minnesota is hiring a Director, Clinical Operations in Eagan, Minnesota. The role provides strategic and clinical leadership for Utilization Management (UM), strengthening practices that support high-quality clinical decision-making, operational excellence, affordability, regulatory compliance, and positive member outcomes. The Director translates enterprise priorities into an operational vision and partners across clinical, medical, product, data, and technology teams to advance performance, quality, and continuous improvement. The position oversees UM programs, staff, and delegated clinical operations; builds accountability with vendors; and uses performance data, operating metrics, and industry benchmarks to guide decisions and improvements. It also drives operational readiness, regulatory and accreditation compliance, business-case execution, stakeholder communications, and adoption of tools and technology that improve efficiency and quality. The Director develops leaders and manages team performance, training, career development, employee relations, and cost control. In partnership with the UM Product Manager, the role is accountable for delivery of Utilization Management Affordability of Care targets. This is a hybrid role requiring at least two days onsite each week, with the remainder of the week remote. The listed annual compensation range is $135,500 to $230,300, with pay dependent on factors including the selected candidate’s skills, ability, and knowledge. Benefits may include medical, dental, and vision insurance, life insurance, 401(k), paid time off, and volunteer paid time off.

Requirements

At least 7 years of progressive health services experience.
At least 3 years of management experience.
Bachelor’s degree, or an additional two years of relevant experience beyond the stated experience qualifications in lieu of a degree.
Strong clinical operations background, preferably in Utilization Management.
Ability to solve complex problems, lead through change, develop leaders, build strategic partnerships, and use performance insights to drive operational improvement.
Current Minnesota state licensure without restriction is listed as preferred in the role description; examples include RN or licensed independent mental health practitioner.

Nice To Haves

Master’s degree in a related field.
Proven leadership of complex Utilization Management operations, including operational strategy, performance, and continuous improvement.
Clinical operations background across Case Management, behavioral health, physical health, or related medical management functions.
Strong partnership with Product teams to align clinical operations with product strategy, priorities, and initiatives.
Demonstrated success developing leaders and guiding teams through growth, ambiguity, and organizational change.
Experience managing vendor partnerships within delegated, onshore, offshore, or blended operating models.
Experience collaborating with medical directors and clinical leaders, including peer-to-peer, pharmaceutical medical review, or related clinical review functions.
Proficiency using dashboards, operational key performance indicators, quality measures, and service-level metrics to identify trends and improve performance.
Strategic problem-solving skills, including assessing enterprise and cross-functional impacts, establishing priorities, and guiding leaders through complex challenges.
Strong communication and facilitation skills, including articulating strategic direction, listening, navigating productive discussions, and building stakeholder alignment.
Adaptability and learning agility to lead effectively in dynamic, less-structured environments.
Healthcare or managed care background and understanding of medical terminology, health insurance, and social determinants of health.
Knowledge of state and federal regulatory and compliance standards, including Medicaid, Medicare, and/or Public Programs.
Current Minnesota state licensure without restriction, such as RN or licensed independent mental health practitioner.

Responsibilities

Provide strategic direction, clinical leadership, and operational oversight for Utilization Management programs and staff.
Drive quality, affordability, compliance, operational performance, and positive member outcomes.
Advance consistent UM practices, sound clinical decision-making, and continuous improvement.
Develop people leaders and guide teams through complex operational challenges and organizational change.
Oversee vendor and delegated clinical operations, ensuring accountability and alignment with UM standards, quality expectations, and performance objectives.
Collaborate with clinical, medical, product, data, and technology teams and with strategic partners and external customers.
Use performance data, operating metrics, quality measures, service-level metrics, and industry benchmarks to identify trends and guide decisions and improvement.
Direct operational readiness and regulatory and accreditation compliance through policies and procedures, program descriptions, auditing, training, and metric monitoring.
Direct the creation, prioritization, and execution of approved business cases.
Communicate program performance and value through presentations, dashboards, RFP content, client meetings, and committee participation.
Lead change by communicating and taking ownership of operational strategy and success criteria.
Build relationships with vendor partners, regulatory bodies, Blue Plan resources, and other external market influencers to identify and communicate value and solutions.
Identify and champion tools and technology that improve operational efficiency and quality.
Partner with workforce management to standardize productivity and quality metrics, monitor team performance, and hold staff accountable to established standards.
Create an environment where Medical Management staff can work effectively at the top of their licensure.
Lead a high-performing team, including interviewing and hiring employees in accordance with EEO and Affirmative Action guidelines and ensuring appropriate training.
Manage employee performance, skill and career development, policy administration, coaching, employee relations, and cost control.
Partner with the UM Product Manager to deliver Utilization Management Affordability of Care targets.
Perform additional responsibilities consistent with the scope and level of the role, as assigned.