Sr. Manager, Medical Informatics - Utilization Management Analytics

Blue Shield of CA; Rancho Cordova (CA); Hybrid; USD 150,000 - 210,000; Full time

Job summary

Blue Shield of CA is seeking a Sr. Manager, Medical Informatics - Utilization Management Analytics in California.

The role leads a team focused on Prior Authorization, Concurrent Review, and broader UM analytics, translating clinical priorities into actionable strategies and driving insights to improve affordability, quality, and member outcomes. The leader will strengthen organizational understanding of utilization and authorization performance, develop capabilities, and partner with

Qualifications

• Requires a Bachelor's degree or High School Diploma/GED with 4 years of additional relevant experience in lieu of a degree.
• 8 years of prior relevant experience in a medical informatics position in healthcare.
• 4 years of people management experience with direct supervision responsibilities.
• Knowledge of legal and regulatory issues for data exchange in the CA health insurance industry.
• Understanding of UM concepts and performance measures (authorization volume, denial rates, timeliness, readmissions, etc.).
• Experience supporting UM, Prior Authorization, Concurrent Review or related clinical functions.
• Experience analyzing CA payer/provider data and interpreting utilization, cost and outcomes measures.
• Experience applying HIPAA and California health data privacy requirements.

Responsibilities

• Lead a team responsible for Prior Authorization and Concurrent Review analytics.
• Translate clinical and operational priorities into actionable analytical strategies.
• Develop team capabilities and deliver insights for operational improvement and executive decision-making.
• Collaborate with payer operations to inform affordability and member outcomes across lines of business.

Skills

Medical informatics

Healthcare analytics

Leadership

HIPAA compliance

Payer analytics

Education

Bachelor's degree or HS diploma

Graduate degree preferred

Job description

Your Role

The Healthcare Quality Affordability (HQA) Analytics team plays a key role in discovering information hidden in vast amounts of data that can lead to smarter decisions and deliver better service for our customers and contain the rising cost of healthcare. The Sr. Manager, Medical Informatics - Utilization Management (UM) Analytics will report to the Director of HQA Analytics and lead a team responsible for Prior Authorization, Concurrent Review, and broader UM analytics. This leader will translate clinical and operational priorities into actionable analytical strategies, strengthen organizational understanding of utilization and authorization performance, develop team capabilities, and deliver insights that inform operational improvement, executive decision-making, affordability, quality, and member outcomes across lines of business.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Knowledge and Experience

• Requires a Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree. A Graduate degree (MPH, MBA, MS, MA, RN, or RHIA) in a relevant field and 2 years of post-degree healthcare analytics experience is preferred
• Requires 8 years of prior relevant experience in a medical informatics position within the healthcare industry
• Requires 4 years of prior people management experience with direct responsibility for supervising, coaching, and evaluating direct reports
• Command of legal and regulatory issues that apply to data exchange, processing, and analysis in the California health insurance industry
• Demonstrated understanding of key UM concepts and performance measures, including authorization volume, approval and denial rates, decision timeliness, inpatient admissions, length of stay, avoidable days, levels of care, readmissions, and authorization-to-claims reconciliation
• Strong knowledge of healthcare payer operations, with direct analytical experience supporting UM, Prior Authorization, Concurrent Review, or related clinical functions is strongly preferred
• Four (4) years of experience analyzing California payer/provider data and interpreting utilization, cost, and outcomes measures is preferred
• Two (2) years of experience applying HIPAA and California health data privacy requirements to data exchange, processing, and analysis is preferred

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.