Vice President of Utilization Management

VillageCare is a community-based, not-for-profit organization serving people with chronic care needs, as well as seniors and individuals in need of continuing care and managed care services. Our mission is to promote healing, better health and well-being to the fullest extent possible. Our care is offered through a comprehensive array of community and residential programs, as well as managed care. VillageCare has delivered quality health care services to individuals residing within New York City for over 45 years.

About the role

The Vice President, Utilization Management is responsible for the development and implementation of plans to optimize the end-to-end operations of all utilization management functions to ensure access to needed services for all members while managing costs. Reporting to the EVP for Clinical Services and Network Management and working in collaboration with the Senior Medical Director, you will lead a team of experienced professionals responsible for assessing member needs relative to applicable clinical guidelines across inpatient, outpatient, and home-based services, and for ensuring compliance with Medicare and Medicaid program rules and requirements.

Through a matrix environment, you will work closely with senior leaders responsible for Finance, Medical Economics, Data Analytics, Care Management, Pharmacy Management, Network Management, and Behavioral Health Management programs to integrate Utilization Management functions within the Clinical Operations team, aiming to achieve positive clinical outcomes and enhance member satisfaction across all VillageCareMAX lines of business. You will also be responsible for the ongoing review and refinement of Utilization Management strategies and plans.

Responsibilities

• Develop and implement plans to optimize end-to-end utilization management operations.
• Lead a team of professionals assessing member needs against clinical guidelines for inpatient, outpatient, and home-based services.
• Ensure compliance with Medicare and Medicaid program rules and requirements.
• Collaborate with senior leaders in Finance, Medical Economics, Data Analytics, Care Management, Pharmacy Management, Network Management, and Behavioral Health to integrate Utilization Management functions.
• Drive positive clinical outcomes and enhance member satisfaction across all VillageCareMAX lines of business.
• Review and refine Utilization Management strategies and plans on an ongoing basis.

Requirements

• Minimum of 8 years of management experience in a health-related field.
• Minimum of 10 years' experience in a utilization management position.
• Hospital-based clinical experience required.
• Experience analyzing and using data to drive improvement activities.
• Track record of successfully managing UM functions in compliance with Medicare and Medicaid rules and requirements.

Qualifications

• Bachelor's Degree in Nursing.
• Master's degree in a related healthcare or business field required.

Pay

$252,259.69 - $277,485.66

Schedule

Hybrid (Must reside in NY/NJ/CT)