Vice President, Utilization Management

This is a fully remote position, open to applicants in Florida.

📋 Description

• Strategically plan and drive the execution of Medical Management utilization programs, processes, and initiatives.

• Ensure the achievement of health benefit ratio targets while effectively reducing utilization-related expenses.

• Provide vision and strategic leadership to promote compliance in utilization management best practices throughout the enterprise.

• Develop tailored strategies for distinct markets and products.

• Collaborate directly with cross-functional teams to assess, enhance, and progress utilization management programs and strategies.

• Lead data-informed decision-making to enhance outcomes for the utilization management team.

• Identify and implement innovative solutions to boost efficiency in the utilization management process.

• Establish standard operating procedures to ensure consistency in utilization quality and service outcomes.

• Design data-driven methodologies to pinpoint opportunities for improving outcomes and lowering costs.

• Spearhead the ongoing development and enhancement of policies, clinical guidelines, and aligned business practices.

• Innovate and execute models for operational functions in utilization management in response to trends in healthcare delivery and emerging care models.

• Ensure that utilization management processes adhere to regulatory requirements.

• Define and interpret critical performance metrics, devise plans, mobilize the workforce, and meet company utilization management objectives.

• Establish and monitor service level agreements to fulfill customer needs.

• Act as a change agent by facilitating decision-making and coaching leaders and staff.

• Carry out other assigned duties as required.

• Adhere to all policies and standards.

⛳️ Requirements

• A Bachelor's Degree in Nursing or a related healthcare field, or equivalent experience is required.

• A minimum of 10 years of experience in managed care, health plan, or provider network organizations is required.

• A current nursing license is mandatory.

• Experience with Managed Medicaid is preferred.

• A Master's Degree in nursing or business is preferred.

• Equivalent experience gained through relevant knowledge, responsibilities, and skills reflective of this position's level is required.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work options including remote, hybrid, field, or office schedules.

• Additional forms of incentives may be included in total compensation, subject to program eligibility.