System VP Utilization Management

About the role

The System Vice President of Utilization Management is a key member of the healthcare organization’s leadership team and is charged with meeting the organization’s goals and objectives for assuring the effective, efficient utilization of health care services.

Responsibilities

• Lead the System-level Utilization Management (UM) department, ensuring alignment with organizational goals and regulatory standards.
• Develop and implement policies, procedures, and strategies that promote high-quality, cost-effective care while enhancing operational efficiencies.
• Drive continuous improvement initiatives, establish key performance indicators (KPIs) to evaluate UM effectiveness, and provide guidance and mentoring to UM team members, including physicians, clinical staff, and administrative staff.
• Apply clinical expertise in reviewing and overseeing the medical necessity of healthcare services, treatments, and procedures. Lead medical review activities, ensuring compliance with regulatory and accreditation requirements, and serve as the clinical authority on complex cases, appeals, and exceptions, ensuring decisions are made based on medical necessity and best practices.
• Collaborate with senior leadership, clinical teams, and external stakeholders to promote a coordinated approach to utilization management. Communicate effectively with physicians, healthcare providers, and insurance representatives to resolve issues related to coverage, care management, and treatment options. Act as a liaison between the organization and external regulatory bodies to ensure compliance with healthcare laws and policies.
• Develop and implement cost-control strategies that reduce unnecessary medical expenses while maintaining high-quality care. Monitor utilization trends and identify opportunities for cost savings through appropriate management of healthcare resources. Collaborate with the Quality Assurance and Medical Affairs departments to improve clinical outcomes and patient safety.
• Ensure UM practices adhere to all state, federal, and insurance company regulations, as well as accreditation standards (e.g., NCQA, URAC). Stay up-to-date with healthcare regulations, industry trends, and best practices in utilization management.

Requirements

• Demonstrated knowledge of nationally recognized medical necessity criteria.
• Capable of working independently with a high level of performance in a rapidly changing, fast-paced environment.
• Current knowledge of federal, state and payer regulatory and contract requirements.
• Previous Physician Advisor/Care Management or equivalent experience. Excellent communication skills – both verbal and written.
• Strong interpersonal communication skills.

Qualifications

• Master’s or Post Graduate Degree with graduation from an accredited medical school required.
• Minimum 10 years of experience working with health care delivery systems, required.
• Minimum 5 years experience in physician advisory, required.
• Minimum 5 years of experience working within or in collaboration with Utilization Management for a health system, required.
• Minimum 5 years of experience working within or in collaboration with Revenue Cycle for a health system, required.
• Minimum 5 years of experience performing government, managed care, and commercial appeals required.
• Minimum 7 years of experience in a director level, or equivalent leadership role, required.
• Prior VP and/or CMO experience greater than 3 years, preferred.

Skills

• Leadership and strategic planning skills.
• Expertise in healthcare policy and regulatory compliance.
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.

Benefits

CommonSpirit Health offers a comprehensive benefits package, including medical, prescription drug, dental, vision plans, life insurance, paid time off, tuition reimbursement, retirement plan benefits, and more. Details can be found on the Total Rewards page.

Pay

The posted compensation range of $133.54 - $186.96 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

Schedule

The System Vice President of Utilization Management works full-time with a weekly schedule of Monday - Friday (8:00am - 5:00pm).