Case Manager responsible for partner onboarding and communication in both Spanish and English. Engaging in stakeholder management and monitoring onboarding progress.
BM
Onsite Senior Manager, Clinical Review
Posted 3 hours ago
About the role
- Senior Manager overseeing utilization review operations for Commercial plans at BCBSMA. Leading clinical teams, ensuring compliance, and improving member outcomes.
Responsibilities
- Directs the utilization review clinical team operations for our Commercial plans
- 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.
- 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.
- Analyze complex utilization data to identify trends, patterns, and opportunities for clinical quality improvement.
Requirements
- A bachelor’s degree in nursing or related clinical field is required
- A master’s degree in healthcare administration, Public Health, Nursing, or a related clinical field is strongly preferred
- 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
- A minimum of 5-7 years of professional experience and progressive leadership in utilization management within a health plan or health system setting preferred.
- Proven experience overseeing utilization review in a managed care organization is highly desirable.
Benefits
- Paid time off
- Medical/dental/vision insurance
- 401(k)
- Suite of well-being benefits
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