Vice President, Utilization Management

Essential Functions

• Establish the enterprise vision and long-term strategy for utilization management.
• Serve as the executive subject matter expert advising the CEO, COO, CFO, CMO, and Revenue Cycle leadership on utilization management payer trends and regulatory risk.
• Provide executive utilization management reporting and performance analytics to leadership and the Board.
• Translate organizational growth goals into operational utilization management initiatives.
• Align hospital operations, medical staff leadership, and revenue cycle functions to system priorities.
• Lead change management for system-wide clinical and operational initiatives affecting patient flow, admissions, and payer performance.
• Develop and execute strategies to improve net patient revenue, reimbursement capture, and denial prevention across all facilities.
• Identify financial leakage within patient status, length of stay, and authorization workflows and implement corrective strategies.
• Oversee enterprise denial management strategy and executive-level payer escalation processes.
• Partner with contracting and revenue cycle leadership to influence payer negotiations using data, trends, and operational leverage.
• Collaborate with medical staff leadership to improve physician engagement, peer-to-peer review success, and appropriate level-of-care determinations.
• Lead initiatives connecting UM, Case Management, CDI, and Quality to improve clinical outcomes and regulatory compliance.
• Ensure regulatory readiness and accreditation performance across all facilities.
• Establish enterprise KPIs and predictive analytics to monitor performance, payer risk, and resource utilization.
• Oversee development of executive dashboards and decision-support tools.
• Use data to drive operational and physician behavior change.
• Evaluate and implement technology platforms supporting utilization management and care coordination.
• Provide executive oversight of Corporate and System Utilization Management leadership.
• Develop leadership capability among facility-level directors and managers.
• Build standardized workflows and governance structures across all facilities.
• Lead cross-department committees involving operations, medical staff, compliance, and revenue cycle.

Requirements

• Master’s Degree in Healthcare Administration, Nursing, Business Administration, or related field preferred.
• 10+ years of progressive healthcare leadership experience.
• Multi-facility or health system leadership required.
• Experience working directly with physicians and senior executives.
• Demonstrated success improving reimbursement, denial reduction, or operational throughput.
• Experience with behavioral health or post-acute healthcare systems preferred.
• Experience with payer negotiations, value-based care, or risk-bearing models.

Skills / Abilities

• Enterprise strategic thinking.
• Executive communication & influence.
• Financial acumen.
• Change leadership.
• Physician relationship management.
• Data-driven decision making.
• Regulatory & compliance expertise.