Manager Utilization Management

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. Family Comes 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. Coordinates with procurement for vendor contracts. Prepare and present information about medical necessity reviews to internal and external customers. Interpersonal skills to effectively and professionally handle sensitive medical necessity, utilization, and cost issues with members, providers, group representatives, and other internal and external customers. Familiarity with enterprise project management methodologies and collaborative planning practices (Agile, Scrum). Education and Experience Bachelor of Science in Nursing (BSN) or a bachelor’s degree in a health related or business field required. Registered Nurse with a minimum of five years of clinical experience required. Minimum 5 years of Utilization Management experience, preferably in a leadership or managed care setting required. Physical Requirements 95% of daily activity requires use of PC Capable of complying with all Kansas laws and regulations regarding the operation and use of motor vehicles. Must have a valid driver’s license. Able to travel, including overnight. Compensation $116,000 - $145,000 annually Exempt Grade 18 Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts. Our Commitment to Connection and Belonging At Blue Cross and Blue Shield of Kansas, we are committed to fostering a culture of connection and belonging, where mutual respect is at the foundation of our workplace. We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law. Blue Cross and Blue Shield of Kansas conducts pre-employment drug screening, criminal conviction check, employment verifications and education as part of a conditional offer of employment.