Director, Behavioral Health Utilization Management

Job Description

Your Role

Blue Shield of California is looking for a clinical leader to oversee the behavioral health utilization management for all product lines. Reporting to the Sr. Director, Behavioral Health Clinical Operations, the role of the Director, Behavioral Health Utilization Management is critical to the success of Blue Shield of California and the Utilization Management department in realizing its goals and objectives. This individual will play a key role as part of Utilization Management team in delivering and collaborating on all aspects of utilization management and care coordination for behavioral health membership for all lines of business. This leader will also provide direction and leadership in compliance to regulatory requirements and key operational metrics.

Responsibilities

Your Work

In this role, you will:

• Manage and monitor prior authorization, concurrent review, and transitions of care/continuity of care to ensure that the patient is getting the right care in a timely and cost-effective way.
• Lead development of Behavioral Health UM strategy by leveraging the use of data/analytics to inform and influence technology solutions to streamline operational efficiencies. Build a cost-benefit methodology to rationalize decisions on UM reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.
• Provide analysis and reports of significant utilization trends, patterns, and resource allocation. Partner with physicians and BH clinicians to develop improved utilization of effective and appropriate services.
• Establish and measures productivity metrics in order to support workforce planning methodology and rationalization of services required to perform UM reviews and adapt to membership growth.
• Ensure alignment of the authorization strategy with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.
• Manage strategic projects and supporting operations initiatives.
• Lead operational implementation of transformation changes (organizational management, process implementation, technology adoption).
• Responsible for utilization management teams' performance, resource management, continuous improvement, and training.
• Responsible for operational audit readiness, ensuring adequate processes and internal audit measures in place and maintained quarterly.
• Ensure all operational processes are meeting regulatory and accreditation requirements
• Ensure front line staff are receiving weekly to monthly one on one coaching celebrating successes and discussing opportunities for improvement.
• Fosters a culture of process excellence, BSC leadership principles, and a great place to work environment

Qualifications

Your Knowledge and Experience

• Current CA RN License, LCSW, LMFT, LPCC, or PsyD by the Board of Behavioral Health Sciences.
• Requires a college degree or equivalent experience and minimum of 10 years prior relevant experience, including 6 years of management experience.
• Certified Case Manager (CCM) or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field.
• Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, CMS, DHCS)
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable
• Requires broad management knowledge to lead project teams in one department/function or large centralized function.
• Master's Degree in a healthcare field preferred

About the Team

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:

o Member-facing and approved out-of-state roles remain remote.

o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.