Director Utilization Management

Blue Cross and Blue Shield of Kansas•Topeka, KS

1d•Hybrid

About The Position

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.

Requirements

Advanced expertise in utilization management principles and workflows, including medical necessity determinations, prior authorization, concurrent and retrospective review, appeals, and denials management, with the ability to standardize and optimize processes to improve efficiency, consistency, and regulatory adherence.
Deep understanding of managed care, payer operations, healthcare delivery systems, and health benefit plan design, including utilization drivers, cost containment, and value‑based care models.
Proven success designing, implementing, and scaling utilization management programs aligned with organizational strategy, quality outcomes, and financial stewardship with demonstrated ability to apply evidence‑based clinical guidelines, medical policy, and coverage determinations to support consistent, compliant utilization and medical review decisions.
Knowledge of regulatory, accreditation, and compliance requirements, including state and federal regulations, Centers for Medicare and Medicaid Services requirements, and corporate compliance standards.
Strong analytical capability with experience translating utilization, clinical, and cost data into actionable operational insights and continuous quality improvement initiatives.
Demonstrated leadership and change management experience, including leading multidisciplinary clinical and non‑clinical teams and developing people leaders.
Strong cross‑functional collaboration and stakeholder influence, partnering effectively with Medical Directors and senior leaders while respecting clinical authority.
Excellent written and verbal communication skills, with the ability to convey complex utilization concepts and data to diverse audiences, including executive leadership.
High level of professional judgment, accountability, and discretion, with a strong commitment to quality, confidentiality, and best practices in utilization management.
Minimum of 8 years of progressive healthcare experience, including utilization management, care management, or clinical operations, with a strong working knowledge of the design and execution of utilization management strategies that reduce total cost of care while improving quality outcomes and patient and provider experience, required.
Minimum of 5 years of experience providing leadership for teams required.
Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

Nice To Haves

Bachelor’s degree in nursing, healthcare administration, public health, or related healthcare field preferred.
In lieu of degree an additional 3 years’ relevant experience required.
Registered Nurse license and/or clinical licensure in the state of practice preferred.

Responsibilities

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 strategies, vendor and delegated entity oversight, and executive-level reporting.