Sr. Manager, Clinical Review

We are seeking a dynamic leader to join our team as the Senior Manager. Clinical Review. This role directs the utilization review clinical team operations for our Commercial plans. The Senior Manager will lead a large clinical team, foster a culture of excellence, and ensure the 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, including subordinate leaders and their teams.
• 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.
• Serve as a key subject matter expert on utilization trends, collaborating with senior leadership on strategic clinical initiatives and program development.

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

Data-Driven Performance Improvement

• Analyze complex utilization data to identify trends, patterns, and opportunities for clinical quality improvement.
• Develop and implement data-driven strategies to manage clinical affordability, reduce avoidable admissions, and optimize resource utilization.
• Lead the implementation of high-impact clinical projects, defining metrics, measuring outcomes, and reporting on program success to leadership.
• 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.

High school degree or equivalent required unless otherwise noted above

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.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan 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 ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto 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.