Vice President, Utilization Management

Position Purpose

Plan and drive execution of Medical Management utilization programs, processes, and initiatives to ensure achievement of health benefit ratio targets, and appropriate reductions in utilization related expenses.

Provide vision and strategic leadership for the development and implementation of compliant utilization management best practices across the enterprise while developing customized approaches for unique markets/product.

Directs the collaboration within cross-functional teams to evaluate, refine, and advance the utilization management program and strategy.

Led data-driven decision making to advance and improve the outcomes of utilization management teams.

Identifies and implements innovative solutions to improve the efficiency of utilization management processes across the enterprise.

Establishes standard operating procedures to drive consistency in utilization quality and service outcomes.

Designs data driven processes to identify areas of opportunity for improving outcomes and reducing costs.

Leads continuous development and improvement of policies, clinical guidelines, and aligned business practices across utilization management functions.

Innovates and implements new or revised models for UM operational functions in response to evolving trends in healthcare delivery and/or emerging models of care.

Serves as a change agent, assisting others in understanding the importance, necessity, impact, and process of change through active involvement in decision making and coaching of leaders and staff.

Ensures UM processes are compliant processes and adhere to regulatory requirements.

Defines and interprets key performance metrics to develop plans, mobilize the work force, and achieve the company’s UM goals.

Establishes and monitors service level agreements to ensure UM programs are meeting customer (health plan, corporate partner, etc.) needs.

Complies with all policies and standards.

Education/Experience

• Bachelor's Degree in Nursing or related healthcare field or equivalent experience required.
• Master's Degree in nursing or business preferred.
• 10+ years of experience in managed care, health plan, or provider network organizations required.
• Experience With Managed Medicaid Preferred.
• Current nursing license required.

Pay Range

$188,900.00 - $359,800.00 per year