Vice President, Utilization Management

Overview:

Oversees and manages the utilization management and medical management functions within VNS Health. Possesses deep expertise in healthcare operations, utilization management processes, prior authorization, regulatory requirements, and operational process improvement. Works closely with cross-functional teams, including medical directors, nurses, care managers, Provider Network Management, Claims, Compliance, Quality, and administrative staff, to ensure efficient and effective utilization of healthcare resources. Ensures the health plan meets the Center for Medicare Services (CMS), State and other external regulations for all medical management and member services areas. This role has a strong focus on process transformation, prior authorization operations, policy development and implementation, documentation standards, regulatory compliance, and continuous improvement. Works under general supervision.

Responsibilities: Qualifications:

Licenses and Certifications:

 

• Clinical licensure is not required. Registered Nurse or other clinical licensure may be preferred based on the candidate’s overall background and experience preferred
• Candidates who hold an RN license outside of New York State may be considered and may obtain New York State licensure after hire

Education: 

 

Bachelor's Degree in healthcare administration, business administration, healthcare management, nursing, or a related field required

 

Master's Degree in healthcare administration, business administration, healthcare management, nursing, or a related field preferred

Work Experience:

 

• Minimum 8 years of progressive experience in utilization management, medical management, prior authorization, healthcare operations, or a closely related managed care function required
• Demonstrated people leadership experience, including responsibility for coaching, developing, training, and managing teams required
• Strong knowledge of prior authorization policies, procedures, workflows, documentation requirements, and operational controls required
• Strong knowledge of CMS requirements impacting utilization management and prior authorization required
• Demonstrated ability to interpret regulatory, policy, and operational requirements and translate them into effective processes and procedures required
• Strong understanding of healthcare reimbursement models, including fee-for-service and value-based care required
• Excellent analytical and problem-solving skills, with demonstrated ability to identify process gaps, determine root causes, develop practical solutions, and drive measurable improvement required
• Proven track record in driving process improvement initiatives and achieving measurable results required
• Demonstrated experience leading significant operational or process change within a complex healthcare or managed care environment required
• Experience developing, implementing, or improving utilization management and/or prior authorization policies, procedures, workflows, and operating controls required
• Experience partnering cross-functionally with Provider Network Management, Claims, Compliance, Quality, Medical Management, and other operational stakeholders required
• Strong leadership abilities, including the ability to inspire and motivate a diverse team required
• Exceptional communication and interpersonal skills, with the ability to collaborate effectively with internal and external stakeholders required
• Ability to establish credibility through depth of subject-matter expertise while remaining open to learning, collaboration, and continuous improvement required

Pay Range: USD $193,600.00 - USD $258,200.00 /Yr.