Sr. Manager, Clinical Review

Blue Cross Blue Shield of Massachusetts • Boston, MA

1d

About The Position

Ready to help us transform healthcare? Bring your true colors to blue. We are seeking a dynamic leader to join our team as the Senior Manager. Clinical Review. This role directs the utilization review clinical team operations for our Commercial plans. The Senior Manager will lead a large clinical team, foster a culture of excellence, and ensure the delivery of medically necessary, high-quality, and cost-effective care. This position is accountable for maintaining rigorous compliance with all regulatory and accreditation standards while driving strategic initiatives to improve member outcomes.

Requirements

• Education: A bachelor’s degree in nursing or related clinical field is required.
• Licensure: Must possess an active, unrestricted clinical license in Nursing or related clinical field (e.g., RN, NP, PA, etc.).
• Must have the ability to secure equivalent licensure within the State of Massachusetts within 6 months of hire date.
• Experience: A minimum of 5-7 years of professional experience and progressive leadership in utilization management within a health plan or health system setting preferred.

Nice To Haves

• A master’s degree in healthcare administration, Public Health, Nursing, or a related clinical field is strongly preferred.
• Proven experience overseeing utilization review in a managed care organization is highly desirable.

Responsibilities

• Strategic & Team Leadership Provide decisive leadership and direct supervision to a clinical staff team, including subordinate leaders and their teams.
• Execute a forward-thinking utilization management strategy that aligns with the company's goals.
• Lead performance management, including hiring, professional development, mentorship, and performance evaluations to build a high-performing, engaged team.
• Foster a culture of clinical excellence, empathy, and member-centered care.
• Serve as a key subject matter expert on utilization trends, collaborating with senior leadership on strategic clinical initiatives and program development.
• Clinical Operations & Quality Assurance Direct all utilization review functions, including pre-service, concurrent, and retrospective reviews, ensuring timeliness and adherence to evidence-based medical necessity criteria and internal medical policies.
• Ensure the utilization management program maintains robust compliance with NCQA accreditation other federal and state regulations.
• Serve as the primary liaison between clinical teams, physician reviewers, and external organizations to resolve complex cases clinical process issues Data-Driven Performance Improvement
• Analyze complex utilization data to identify trends, patterns, and opportunities for clinical quality improvement.
• Develop and implement data-driven strategies to manage clinical affordability, reduce avoidable admissions, and optimize resource utilization.
• Lead the implementation of high-impact clinical projects, defining metrics, measuring outcomes, and reporting on program success to leadership.
• Drive process improvement and identify opportunities to increase staff productivity and operational efficiency.

Benefits

• We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager