Manager Utilization Management

Blue Cross and Blue Shield of Kansas•Topeka, KS

2d•Hybrid

About The Position

The Manager of Utilization Management leads medical necessity review functions, including precertifications, concurrent reviews, alternative care setting authorizations, and pre-service requests. This role ensures evidence-based, complaint care across all lines of business while partnering with internal teams, providers, and vendors to optimize outcomes, drive quality improvement, and maintain regulatory accreditation standards. 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.

Requirements

Awareness and understanding of medical necessity, utilization patterns, standards of practice, and health care environment as they relate to all programs and staffing.
Demonstrated ability to communicate effectively across multiple channels while maintaining professionalism and confidentiality.
Effective time management, independent decision-making, and prioritization skills with flexibility to respond to changing priorities.
Ability to obtain and analyze utilization, system, and workflow data.
Coordinates with procurement for vendor contracts.
Prepare and present information about medical necessity reviews to internal and external customers.
Interpersonal skills to effectively and professionally handle sensitive medical necessity, utilization, and cost issues with members, providers, group representatives, and other internal and external customers.
Familiarity with enterprise project management methodologies and collaborative planning practices (Agile, Scrum).
Bachelor of Science in Nursing (BSN) or a bachelor’s degree in a health related or business field required.
Registered Nurse with a minimum of five years of clinical experience required.
Minimum 5 years of Utilization Management experience, preferably in a leadership or managed care setting required.
95% of daily activity requires use of PC
Capable of complying with all Kansas laws and regulations regarding the operation and use of motor vehicles.
Must have a valid driver’s license.
Able to travel, including overnight.

Responsibilities

Lead Utilization Management operations for pre-service requests, predeterminations, and concurrent reviews, ensuring adherence to all regulatory and accreditation requirements.
Maintain current knowledge on industry trends, clinical research, standards of care, and evidence‑based guidelines to guide appropriate care and comprehensive Utilization Management practices.
Support and advance quality management initiatives that measure, monitor, and improve quality-based activities and outcomes, including programs such as HEDIS, QRS, QIS, and Stars.
Drive accountability and performance excellence across teams through objective performance management and regular Inter‑Rater Reliability testing to ensure consistent Utilization Management decision‑making.
Serve as a Subject Matter Expert for URAC Health Utilization Management Accreditation, FEP UM activities, Mental Health Parity, as well as ensuring all jobs functions are performed within the scope of the Kansas Nurse Practice Act.
Manage departmental budgets responsibly, ensuring proactive and intentional financial stewardship across all teams.
Act as the primary liaison for Blue Card care management activities, collaborating with provider relations, sales, and other internal partners to resolve provider issues and support special business arrangements.
Oversee vendor relationships through effective delegated oversight, ensuring UM activities meet accreditation standards and comply with state and federal regulations, including CMS and Medicare Advantage requirements.
Use data insights to guide operational improvements, accelerate divisional goals, and foster a positive, high‑performance culture that inspires exceptional work.
Lead and develop UM staff, fostering a culture of accountability and continuous improvement.
Assign work, evaluate performance, and support workflow optimization.