Associate Vice President, Utilization Management

Job Summary:
The Associate Vice President, Utilization Management provides strategic leadership and enterprise oversight for Utilization Management review activities and initiatives. This role is accountable for executing UM strategy, driving sustained operational performance, and ensuring the effective alignment and integration of people, processes, and systems. Through disciplined execution, strong cross-functional partnership, and data-driven decision-making, the role advances compliant, efficient, and high-quality utilization outcomes that support organizational objectives, regulatory requirements, and long-term business strategy.
Essential Functions:

• Accountable in the execution of department metrics, goals, and key objectives across utilization management
• Partner with Enterprise and Market leadership on the development of overall program strategy and business objectives
• Establish objectives and annual goals in conjunction with the Vice President of Utilization Management
• Participate in the development of the quality strategy and execute defined initiatives to achieve quality goals
• Manage execution of meeting or exceeding all appropriate clinical and clinical operation requirements by Federal, State, and Accrediting bodies
• Accountable for translating UM program vision and strategy into clinical and operational tactics and collaborating to build the necessary divisional market infrastructure and matrix support
• Foster and influence the UM operational model ensuring goals, and team performance are on track and on par with Enterprise
• Lead large scale transformational change, working effectively with all levels of the organization
• Foster external and internal intra/interdepartmental relationships with hospitals, physicians, community agencies, trade associations and key vendors
• Collaborate with Provider/Health Partner Relations and Community Stakeholders to facilitate access, address barriers to care and improve coordination that support health care outcomes
• Develop and monitor UM policies, procedures and goals as needed to align with the regulatory and accreditation requirements and CareSource strategy/model
• Develop and manage the annual operating and capital budgets, monitor health plan budgets, and describe variance detail monthly with effective action plans
• Create and lead Quality and Affordability Initiatives, revenue generating, Medical and Administrative cost efforts for UM; develop and monitor clinical and clinical operational efficiencies initiatives
• Participate and represent CareSource internally and externally with speaking engagements, State and regional committee work
• In collaboration with Enterprise, conduct a program evaluation annually outlining the effectiveness of the UM program and develop and create monitoring activities to improve effectiveness of UM performance and delivery
• Maintain integrity compliance with all local, state, and federal rules and regulations
• Produce and lead team results at all levels that demonstrate compliant UM performance, Continuous Improvement, and Human Capital metrics that demonstrates leadership behavior is supporting improved outcomes, positive culture and consumer experience
• Maintain an in-depth knowledge of the company’s business, and regulatory environments
• Oversee clinical authorization processes to ensure the effective and efficient delivery of care to members while maintaining compliance with regulations and achieving internal financial objectives
• Provide strategic oversight of clinical staff performing reviews to optimize care delivery, reduce unnecessary services and enhance provider relationships
• Perform any other job related duties as requested.

Education and Experience:

• Bachelor's Degree required
• Master's Degree in Business or Health Care preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Ten (10) years of experience in managed care or clinical operations required
• Five (5) years of leadership/management experience required
• Prior experience with and knowledge of utilization management documentation and managed care systems required

Competencies, Knowledge and Skills:

• Proficient with Microsoft Office, including Outlook, Word and Excel
• Knowledge of Regulatory and Compliance for managed care programs/plans
• Knowledge of NCQA, Quality, STARS, HEDIS and performance improvement methodology
• Knowledge of provider operations
• Strong financial background with proven ability to drive Quality and Affordability
• Strong interpersonal skills
• Ability to influence goals and metrics across a heavily matrix organization
• Knowledge of managed care industry, trends, and accreditation
• Excellent verbal and written communication skills
• Excellent leadership, management and supervisory skills
• Ability to work independently and within a team environment
• Attention to detail and work plan creation, implementation, and evaluation
• Negotiation skills/experience
• Independent decision making/problem solving and innovation skills
• Proven track record in driving continuous improvement efforts to improve member experience and tracked results
• Critical listening and systematic thinking skills
• Ability to attract, manage and develop team members; Inspirational Leadership
• Strategic management skills
• Planning, problem identification, and resolution skills

Licensure and Certification:

• Current, unrestricted license in the state of practice as a Registered Nurse (RN) required
• Compact Registered Nurse (RN) license preferred
• Managed Care, Utilization Management Case Management and/or Quality Improvement certification preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Ability to travel as required by the needs of the department.

Compensation range $150,000-$300,000.  CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Energize and Inspire the Organization

• Influence Others

• Pursue Personal Excellence

• Understand the Business

 

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.#LI-SW2