Are you a strategic and compassionate leader with a deep understanding of Utilization Management (UM)? Blue Cross of Idaho is looking for an experienced professional to lead our Utilization Management team and ensure the delivery of high-quality, cost-effective, and medically necessary care across all lines of business.
Experience: 7 years’ relevant experience to include leadership and 3 years of UM and discharge planning experience
Education: Associates Degree in Nursing or Bachelor’s Degree in Social Work; or equivalent work experience (Two years’ relevant work experience is equivalent to one-year college)
Licenses/Certifications: Must hold one of the following:
- Valid unrestricted Idaho Registered Nurse Licensure
- Valid unrestricted Idaho Social Work Licensure
What You’ll Do:
- Manage prospective and concurrent UM programs, including prior authorizations, inpatient reviews, discharge planning, and post-payment provider inquiries.
- Ensure high-quality, cost-effective, and medically necessary care through evidence-based review processes.
- Provide oversight of UM functions related to both medical and behavioral health services.
- Lead, coach, and develop a multidisciplinary team while fostering operational excellence and regulatory compliance.
- Analyze performance data, ensure workflow efficiency, and drive service-level excellence.
- Develop and implement training, policies, desk procedures, and quality assurance activities.
- Collaborate across Case Management and Care Coordination teams to enhance program impact and outcomes.
- Report to the Director of UM and support strategic planning, staffing, and budgeting efforts.
Required Skills:
- Knowledge of both medical and behavioral health utilization practices, regulatory standards, and health plan operations.
- Proven skills in team leadership, compliance, workflow optimization, and data-informed decision-making.
- Excellent communication, coaching, and cross functional collaboration skills.
- Experience with healthcare delivery systems and regulatory standards (e.g., NCQA, CMS).
- Proficiency with medical management systems, analytics, and reporting tools.
As of the date of this posting, a good faith estimate of the current pay range is $115,898.00 to $173,846.00. The position is eligible for an annual incentive bonus (variable depending on company and employee performance.
The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, internal equity, geography, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.
We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program.
We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.
Reasonable accommodations
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
Top Skills
What We Do
Since 1945, we’ve taken our role as an Idaho-based health insurance company to heart. While the health insurance marketplace has experienced lots of change in recent years, we haven’t. As a not-for-profit, we’re mission-driven to help connect Idahoans to quality healthcare that is affordable and build strong networks and services with our customers in mind.
With an annual economic impact of $456 million (in 2016), we lead the state and industry in addressing the cost of healthcare and creating transformative customer experiences with information, tools and services. Ultimately, we aim to create a brighter future for all of us. All we need are customer-centric leaders like you.
