AVP, Utilization and Care Management Strategy

Responsibilities

• Lead enterprise Medicaid utilization and care management strategy, including prior authorization strategy, Medicaid clinical policy governance, medical expense strategy, site-of-care optimization, provider practice variation, high-risk member strategy, and targeted affordability initiatives.
• Establish strategic direction, governance routines, performance expectations, and enterprise priorities for Medicaid utilization and care management, in partnership with operational leaders accountable for day-to-day execution.
• Oversee Medicaid care management strategy at the enterprise level to ensure programs are member-centered, data-driven, clinically effective, operationally scalable, and aligned with utilization, quality, access, regulatory, and affordability goals.
• Integrate utilization management and care management strategies to identify members with rising risk, complex needs, avoidable utilization, care gaps, and opportunities for earlier intervention, improved care coordination, and more appropriate site-of-care decisions.
• Use utilization, authorization, denial, appeal, claims, care management, quality, medical expense, and member risk data to identify strategic opportunities, evaluate program performance, and recommend actions that improve outcomes while responsibly managing total cost of care.
• Oversee Medicaid clinical policy governance and medical necessity criteria in partnership with clinical and operational stakeholders to ensure policies are evidence-based, clinically appropriate, operationally feasible, member-centered, and compliant with state and federal requirements.
• Partner with Clinical Operations, Care Management, Population Health, Behavioral Health, Pharmacy, and market leaders to modernize utilization and care management approaches, improve provider experience, support administrative simplification strategies such as gold carding, and ensure appropriate access to medically necessary care.
• Identify and prioritize major medical cost and utilization drivers, including high-cost utilization, specialty services, avoidable admissions, emergency department use, readmissions, post-acute care, transitions of care, site-of-care opportunities, gaps in care coordination, and unwarranted variation across markets.
• Advance strategic approaches that connect utilization insights to care management interventions, including improved referral pathways, transitions-of-care strategies, complex care management models, condition-specific interventions, and coordination for members with physical health, behavioral health, pharmacy, and social needs.
• Partner with Finance, Actuarial, Medical Economics, Analytics, and market leadership to establish executive scorecards, business cases, ROI frameworks, savings validation approaches, and performance management processes to track progress, quality impact, operational risks, and emerging opportunities.
• Partner with Medicaid clinical operations and market leadership to understand state-specific regulatory requirements, provider dynamics, local performance opportunities, care management requirements, population health priorities, and operational constraints.
• Support implementation of enterprise strategies with appropriate market flexibility and help scale leading practices across Medicaid markets.
• Serve as a strategic partner to Payment Policy, Payment Integrity, and Fraud, Waste, and Abuse teams to ensure Medicaid priorities, risks, and opportunities are incorporated into enterprise affordability and program integrity efforts. This includes identifying opportunities to improve payment accuracy, reduce avoidable waste, and strengthen stewardship of healthcare resources.
• Evaluate and shape strategy for selecting vendors and external partners supporting utilization management, care management, clinical decision support, affordability programs, population health interventions, and medical cost management capabilities. This includes developing business cases, defining outcome expectations, monitoring performance, and ensuring vendor activities align with clinical, operational, financial, compliance, contractual, quality, and member experience objectives.
• Provide strategic direction for programs that improve care transitions, reduce avoidable inpatient and emergency department utilization, support appropriate post-acute management, improve engagement of high-risk members, and strengthen coordination across providers, plans, and community-based resources.
• Ensure utilization and care management strategies support Medicaid regulatory expectations, health equity, access to care, whole-person health, quality performance, and the needs of medically and socially complex populations.

Qualifications

• 10+ years with leadership experience in Medicaid, managed care, utilization management, care management, clinical strategy, affordability, medical cost management, population health, or clinical operations.
• Licensed clinical background, including MD, DO, RN, NP, PA, PharmD, LCSW, or other relevant clinical credential.
• Strong understanding of Medicaid managed care, state and federal regulatory requirements, utilization management, care management models, clinical policy, provider delivery systems, member risk stratification, population health, and medical expense drivers.
• Demonstrated experience leading enterprise, segment-wide, or multi-market initiatives that influence total cost of care, utilization performance, care management effectiveness, quality outcomes, provider experience, member access, and regulatory performance.
• Proven ability to lead through influence in a complex matrixed environment and align senior stakeholders across market, clinical, operational, financial, actuarial, network, quality, analytics, population health, care management, and program integrity functions.
• Strong analytical capability with experience interpreting claims, utilization, authorization, denial, appeal, care management, provider variation, medical expense, quality, and savings performance data.
• Proven ability to translate strategic priorities into executable roadmaps with measurable outcomes, governance routines, executive-level reporting, and performance monitoring.
• Strong executive communication, presentation, stakeholder management, and change leadership skills.
• Bachelor’s degree in a relevant field such as healthcare administration, nursing, public health, business administration, health policy, finance, or a related discipline, or equivalent relevant experience.