RN Manager, Case Management / Utilization Management

Ready to Help Us Transform Healthcare? Bring Your True Colors to Blue.

The Role

We are seeking a dynamic leader to join our team as the Manager, Clinical Review. This role directs the utilization review clinical team operations for our Commercial plans. The manager will lead a clinical team, foster a culture of excellence, and ensure 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.

Key Responsibilities

Strategic & Team Leadership

• Provide decisive leadership and direct supervision to a clinical staff team.
• 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.

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 and other federal and state regulations.
• Serve as the primary liaison between clinical teams, physician reviewers, and external organizations to resolve complex cases and clinical process issues

Data-Driven Performance Improvement

• Analyze complex utilization data to identify trends, patterns, and opportunities for clinical quality improvement.
• Drive process improvement and identify opportunities to increase staff productivity and operational efficiency.

Qualifications

• Education: 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.
• 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.
• Proven experience overseeing utilization review in a managed care organization is highly desirable.

Location

Hingham

Time Type

Full time Salary Range: $104,580.00 - $127,820.00

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

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.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join our Talent Community to stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our " How We Work " Page.