Sr. Manager, Medical Informatics - Utilization Management Analytics

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.

Responsibilities Your Work

In this role, you will:

Lead, develop, and mentor a team of analysts supporting Prior Authorization, Concurrent Review, and broader UM analytics

Define and execute the UM analytics strategy and roadmap in alignment with organizational, clinical, regulatory, and affordability priorities

Serve as the primary analytics partner to Prior Authorization, Concurrent Review, and Medical Management leadership, translating business needs into actionable analytical strategies

Oversee analytics related to authorization volume, approval and denial rates, decision timeliness, inpatient utilization, length of stay, avoidable days, readmissions, and other key UM performance indicators

Evaluate the impact of UM programs, clinical policies, prior authorization requirements, and operational interventions on utilization, cost, quality, and member and provider experience

Direct complex analyses integrating authorization, clinical, membership, provider, claims, and financial data to identify performance gaps, emerging risks, and improvement opportunities

Partner with Medical Management, Network Management, Claims, Pharmacy, Appeals and Grievances, Compliance, Finance, Product, Technology, and data teams to deliver comprehensive insights and recommendations

Oversee the development of dashboards, recurring reporting, self-service tools, and executive performance summaries using Tableau, Power BI, and other analytical platforms

Establish consistent definitions, methodologies, governance, documentation, and quality-control standards for UM reporting and analytics

Present findings and recommendations to senior leadership and monitor resulting actions to ensure analytics translate into measurable operational improvements

Qualifications 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.

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.

Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.

Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

For most teams, this means coming into the office two days per week.

Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.

For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.