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Manager Utilization Management

Blue Cross Blue Shield of Kansas
  • Topeka, Kansas
    30+ days ago

    Job Description

    Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.

    Why Join Us?
    • Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
    • FamilyComes First: Total rewards package that promotes the idea of family first for all employees. Paid vacation and sick leave with paid maternity and paternity available immediately upon hire
    • Professional Growth Opportunities: Advance your career with ongoing training and development programs.
    • Dynamic Work Environment: Collaborate with a team of passionate and driven individuals in a work environment that promotes flexibility.
    • Trust and Stability: Work for one of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.
    • Inclusive Work Environment: We pride ourselves on fostering a workplace where everyone is valued and respected.

    Benefits & Perks
    • Base compensation is only one component of your competitive Total Rewards package
    • Incentive pay program (EPIP)
    • Health/Vision/Dental insurance
    • 6 weeks paid parental leave for new mothers and fathers
    • Fertility/Adoption assistance
    • 2 weeks paid caregiver leave
    • 401(k) plan matching up to 5%
    • Tuition reimbursement
    • Health & fitness benefits, discounts and resources

    Job Summary

    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."

    What you'll do
    • 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.

    What you need

    Knowledge/Skills/Abilities
    • 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.
    • Coordina

    Numbers & Facts

    LocationTopeka, Kansas

    Skills

    • Accreditation Standardsunmatched
    • Budget Managementunmatched
    • Business Supportunmatched
    • Centers for Medicare and Medicaid Services (CMS)unmatched
    • Clinical Researchunmatched
    • Communication Skillsunmatched
    • Continuous Improvementunmatched
    • Dental Insuranceunmatched
    • Establish Prioritiesunmatched
    • Federal Laws and Regulationsunmatched
    • Fitnessunmatched
    • Healthcareunmatched
    • Healthcare Effectiveness Data and Information Set (HEDIS)unmatched
    • Incentive Programsunmatched
    • Industry/Trade Analysisunmatched
    • Inside Salesunmatched
    • Maintain Complianceunmatched
    • Maintenance Servicesunmatched
    • Medicareunmatched
    • Nursingunmatched
    • Operational Improvementunmatched
    • Patient Care Authorizationsunmatched
    • Performance Managementunmatched
    • Problem Solving Skillsunmatched
    • Process Improvementunmatched
    • Provider Relationsunmatched
    • Psychiatry and Mental Healthunmatched
    • Quality Assuranceunmatched
    • Quality Managementunmatched
    • Quality Monitoringunmatched
    • Regulationsunmatched
    • Regulatory Complianceunmatched
    • Reliability Testingunmatched
    • Standards of Careunmatched
    • State Laws and Regulationsunmatched
    • Stewardshipunmatched
    • Supplier Optimizationunmatched
    • Systems Analysisunmatched
    • Team Playerunmatched
    • Time Managementunmatched
    • Training Programunmatched
    • Training/Teachingunmatched
    • Utilization Managementunmatched
    • Utilization Review Accreditation Commission (URAC)unmatched
    • Vendor/Supplier Relationsunmatched
    • Vision Planunmatched

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