RN Manager, Case Management​/Utilization Management

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Manager, Clinical Review—directs utilization review clinical team operations for our Commercial plans. The manager leads a clinical team, fosters a culture of excellence, and ensures delivery of medically necessary, high‑quality, and cost‑effective care.

• Provide decisive leadership and direct supervision to a clinical staff team.
• Execute a forward‑thinking utilization management strategy that aligns with company 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.
• Direct all utilization review functions—pre‑service, concurrent, and retrospective reviews—ensuring timeliness and adherence to evidence‑based medical necessity criteria and internal medical policies.
• Maintain robust compliance with NCQA accreditation and other federal and state regulations.
• Serve as primary liaison between clinical teams, physician reviewers, and external organizations to resolve complex cases and clinical process issues.
• 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.

• Education:
  
  Bachelor’s degree in nursing or related clinical field required;
  Master’s degree in healthcare administration, public health, nursing, or related field strongly preferred.
• Licensure:
  Must possess an active, unrestricted clinical license in nursing or related field (e.g., RN, NP, PA); must be able to secure equivalent licensure in Massachusetts within 6 months of hire.
• Experience:
  
  Minimum 5–7 years of progressive leadership in utilization management within a health plan or health system; proven experience overseeing utilization review in a managed care organization desired.
• Minimum education requirement: high school degree or equivalent unless otherwise noted above.

Location:

Hingham. Time type:
Full time. Salary range: $ – $. Salary may be modified. This role is also eligible for variable pay.

Benefits include paid time off, medical, dental, vision insurance, 401(k), and a suite of well‑being benefits for eligible employees.

Blue Cross Blue Shield of Massachusetts is an Equal Employment Opportunity employer and will not discriminate on the basis of race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other protected characteristic. Applicants are considered for all positions without regard to the above.