VP, Managed Care

VP, Managed Care Location: 100% Remote in U.S.Company Size: 100-200 employees Opportunity Newly created executive role reporting directly to the CEO, responsible for building and leading the organization's Managed Care function across Medicare Advantage (MAPD).The VP will oversee Risk Adjustment, Utilization Management, and Care Management, with accountability for clinical and financial performance, regulatory compliance, medical cost, quality, and member outcomes. Why This Role Build and shape the Managed Care function from the ground up.Lead a team of 7 across Risk Adjustment, Utilization Management, and Care Management.Develop an integrated operating model across previously separate functions.Drive measurable improvement in risk-adjusted revenue, utilization, medical cost, quality/Stars, and member outcomes.Work closely with executive leadership, Finance, Actuarial, Analytics, Clinical Operations, Network, Quality, Compliance, and other key functions.Performance-focused leadership role (not a contract-negotiation position) Key Responsibilities Set the strategy and operating model for Risk Adjustment, Utilization Management, and Care Management.Optimize Medicare Advantage risk adjustment, diagnosis capture, documentation, coding, and encounter data.Oversee UM programs, including authorization, utilization review, clinical appropriateness, and cost management.Lead care management and population health programs for high-risk, complex, and high-cost members.Integrate Risk, UM, and Care Management to identify opportunities to improve outcomes and plan economics.Partner with Finance, Actuarial, Analytics, Network, and Clinical teams to identify and reduce avoidable medical cost and utilization.Align managed care programs with Medicare Advantage quality/Stars objectives.Ensure CMS regulatory and audit readiness, including RADV.Establish executive dashboards, performance metrics, and ROI measurement.Build a high-performing organization and develop leaders, talent, processes, and infrastructure to support growth. Measures of Success Improved risk-adjusted revenue, RAF/HCC performance, and coding accuracy.Reduced avoidable utilization and medical expense.Improved management of high-risk/high-cost members and care outcomes.Strong UM performance and regulatory compliance.Improved provider engagement and performance.Alignment across Risk Adjustment, UM, Care Management, and Quality/Stars.Demonstrated ROI from managed care initiatives.Scalable infrastructure supporting Medicare Advantage growth. First 12 Months Establish an integrated Risk Adjustment, UM, and Care Management strategy.Assess current operations and establish measurable performance targets.Implement executive dashboards covering risk, utilization, medical cost, quality, and care management.Strengthen risk adjustment and provider documentation initiatives.Evaluate and improve UM effectiveness and utilization outcomes.Build an integrated high-risk/high-cost member strategy and UM-to-Care Management referral model.Identify and prioritize the highest-value medical cost opportunities.Strengthen CMS/RADV readiness and establish a multi-year technology and analytics roadmap. Required Qualifications 10+ years of progressive healthcare leadership experience.Significant Medicare Advantage managed care experience.Leadership experience across at least two of: Risk Adjustment, Utilization Management, Care Management, Population Health, Medical Management, Medical Economics, or Value-Based Care.Strong knowledge of CMS Medicare Advantage requirements.Demonstrated ability to improve both clinical outcomes and financial performance.Experience leading complex clinical/managed care operations and cross-functional teams.Strong analytical, strategic, executive communication, and organizational leadership skills.Bachelor's degree required; master's degree strongly preferred. Preferred MAPD and Medicare Part D experience.CMS-HCC, encounter data, RADV, and CMS audit experience.Experience with Medicare Advantage Stars and quality programs.Value-based care, delegated risk, or provider performance experience.Experience with clinical analytics, predictive modeling, automation, or AI-enabled workflows.Experience in a health plan, IPA, ACO, integrated delivery system, or value-based care organization. By submitting to this position, you are agreeing to be included in our talent pool for future hiring for similarly qualified positions. Equal Opportunity Notice Highspring LLC (d/b/a Vaco by Highspring) and its parents, affiliates, and subsidiaries ("we," "our," or "Vaco by Highspring") are committed to the full inclusion of all qualified individuals and does not discriminate against any employee or applicant for employment because of race (including but not limited to traits historically associated with race such as hair texture and hair style), color, sex (includes pregnancy or related conditions), religion or creed, national origin, citizenship, age, disability, status as a veteran, union membership, ethnicity, gender, gender identity, gender expression, sexual orientation, marital status, political affiliation, or any other protected characteristics as required by applicable law. The company is also committed to ensuring that persons who need them are provided with reasonable accommodations; if an accommodation is needed to participate in the job application or interview process, please contact HR@vaco.com . Vaco by Highspring also wants all applicants to know their rights that workplace discrimination is illegal. Representation Notice By submitting to this position, you agree that you will be giving Vaco by Highspring the exclusive right to present your as a candidate for the foregoing employment opportunity. Additionally, you agree to be included in our talent pool for future hiring for similarly qualified positions. You further agree that you have represented information about yourself accurately and have not affirmatively misrepresented your qualifications. Lastly, you agree to maintain as confidential, to the fullest extent permitted by law, any information you learn from Vaco by Highspring about the position and you will limit disclosure of information about the position only to the extent necessary to perform any obligations in furtherance of your application. In exchange, Vaco by Highspring agrees to exercise reasonable efforts to represent you through all solicitation, job screening and resume dispersal. For residents of Ontario, Canada only: to the extent the position for employment is not with Highspring or not otherwise noted as vacant above, candidate should be informed that this role is to replace a presently employed person at Vaco by Highspring's client. Privacy Notice Vaco by Highspring respects your privacy and are committed to providing transparent notice of our policies. California residents may access Vaco by Highspring HR Notice at Collection for California Applicants and Employees here. Virginia residents may access our state specific policies here. Residents of all other states may access our policies here. Canadian residents may access our policies in English here and in French here. Residents of countries governed by GDPR and UK GDPR may access our policies here. Additionally, submissions to this position are subject to the use of AI to perform preliminary candidate screenings, focused on ensuring minimum job requirements noted in the position are satisfied. More details about Vaco by Highspring's use of AI can be found here (https://www.highspring.com/ai-use-notices/). Further assessment of candidates beyond this initial phase will be conducted by recruiters and hiring managers. Vaco by Highspring does not know and cannot opine on if its client's use of AI products in hiring. Pay Transparency Notice Determining compensation for this role (and others) at Vaco by Highspring depends upon a wide array of factors including but not limited to: · the individual's skill sets, experience and training; · licensure and certification requirements; · office location and other geographic considerations; and · other business and organizational needs. With that said, as required by local law, Vaco by Highspring believes that the following salary range referenced above reasonably estimates the base compensation for an individual hired into this position in geographies that require salary range disclosure. The individual may also be eligible for discretionary bonuses and/or participation in medical, dental, and vision benefits as well as the company's retirement plan (or similar retirement benefits).