Director Clinical Operations - Utilization Management

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing.

If you are ready to make a difference, join us.

Blue Cross and Blue Shield of Minnesota is hiring a Director, Clinical Operations in Eagan, MN. In this role, you will provide strategic and clinical leadership for Utilization Management (UM), strengthening practices that support high-quality clinical decision-making, operational excellence, affordability, and positive member outcomes. You will build strong internal and external partnerships while advancing performance, quality, and continuous improvement. You will translate enterprise priorities into a clear operational vision while partnering across clinical, medical, product, data, and technology teams.

The ideal candidate brings a strong clinical operations background, preferably in Utilization Management, with the ability to solve complex problems, lead through change, develop leaders, build strategic partnerships, and use performance insights to drive informed decisions and operational improvement.

• Direct clinical and operational leadership of Utilization Management, driving quality, affordability, compliance, and positive member outcomes.
• Advance consistent and effective UM practices that support sound clinical decision-making, operational performance, and continuous improvement.
• Develop people leaders who translate enterprise and clinical strategy into clear priorities and guide teams through complex operational challenges and change.
• Oversee vendor and delegated clinical operations, strengthening accountability and alignment with UM standards, quality expectations, and performance objectives.
• Collaborate across clinical, medical, Product, data, and technology teams to solve complex problems and align operational priorities with broader strategy.
• Leverage performance data, operating metrics, and industry benchmarks to identify trends, establish priorities, and guide strategic and operational decisions.

• Provide strategic direction, leadership, and operations oversight to programs and staff to optimize efficiency and effectiveness of Utilization Management operations, deliver positive health outcomes, meet/exceed performance guarantees and increase stakeholder satisfaction.
• Collaborate with strategic partners and external customers to innovate, design and deliver operational rigor that supports the utilization management product strategy and delivers value to customers in alignment with corporate and divisional priorities.
• Direct operational readiness and regulatory/accreditation compliance via formal processes such as policy and procedure, program descriptions, auditing, training, and metric monitoring and management.
• Lead the evaluation of operational performance based on performance against industry benchmarks and acts on opportunities to enhance and improve.
• Direct the creation, prioritization, and execution of approved business cases.
• Lead the creation and communication of program performance value through formal and informal presentations, dashboards, RFP content, client meetings and committee participation.
• Serves as a change leader supporting, communicating and taking personal ownership of operational strategy and success criteria.
• Leverage vendor partners and build a network among external market influencers, including regulatory bodies and Blue Plan resources, to bring new ideas and solutions that increase the value delivered to all stakeholders and to communicate existing value to the market.
• Constantly scans the market for tools and technology that will improve operational efficiency and quality.
• Champions adoption and implementation of those tools that will drive business value.
• Partners with workforce management to drive toward standardized metrics to measure productivity and quality.
• Establishes process to continually monitor teams’ progress against established standards and holds staff accountable to meeting standards.
• Create and foster an environment where Medical Management staff can work effectively and efficiently at the top of their licensure.
• Leads and directs a high…