Director Clinical Operations - Utilization Management

About Blue Cross and Blue Shield of Minnesota

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.

The Impact You'll Have


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.



What You'll Do

• •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.




How You'll Do It

• •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 performing team including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive the proper training. Conducts performance evaluation and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations and cost control.
• •With the UM Product Manager, is accountable for the delivery of utilization management Affordability of Care (AOC) targets
• •Performs additional responsibilities consistent with the scope and level of the role, as assigned.




Required Skills & Experience

• •7+ years of progressive health services experience with 3+ years of management experience.
• •Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the qualifications listed above may be accepted.

Preferred Skills & Experience

• •Master’s degree in a related field.
• •Proven leadership of complex Utilization Management operations, including operational strategy, performance, and continuous improvement.
• •Clinical operations background across Case Management, behavioral health, physical health, or related medical management functions.
• •Strong partnership with Product teams to align clinical operations with product strategy, priorities, and initiatives.
• •Demonstrated success developing leaders and guiding teams through growth, ambiguity, and organizational change.
• •Background managing vendor partnerships within delegated, onshore, offshore, or blended operating models.
• •Collaboration with medical directors and clinical leaders, including peer-to-peer, pharmaceutical medical review, or related clinical review functions.
• •Proficiency using dashboards, operational key performance indicators, quality measures, and service-level metrics to identify trends and improve performance.
• •Strategic problem-solving skills with the ability to assess enterprise and cross-functional impacts, establish priorities, and guide leaders through complex challenges.
• •Strong communication and facilitation skills to articulate strategic direction, actively listen, navigate productive discussions, and build stakeholder alignment.
• •Adaptability and learning agility to lead effectively in dynamic, less-structured environments.
• •Healthcare or managed care background with an understanding of medical terminology, health insurance, and social determinants of health.
• •Knowledge of state and federal regulatory and compliance standards, including Medicaid, Medicare, and/or Public Programs.
• •Current MN state licensure without restriction (i.e., RN or licensed independent mental health practitioner preferred)




Licensure/Certifications


Nice to have: Current MN state licensure without restriction (i.e., RN or licensed independent mental health practitioner)



Role Designation


Hybrid

 Role designation definition:

• •Teleworking is working full time remote.
• •Hybrid is a minimum of 2 days onsite.
• •Onsite is full-time onsite.

Anchored in Connection

Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week – most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships, creativity, and alignment. The rest of the week you ar