VP of Utilization Review

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

📋 Description

• Provides executive oversight and strategic leadership for all enterprise Utilization Review operations across various facilities, service lines, and states.

• Develops and enacts standardized UR processes, workflows, policies, and documentation standards across the enterprise to enhance operational consistency and payer outcomes.

• Manages authorization processes, concurrent reviews, denial prevention strategies, appeals handling, retrospective reviews, and payer escalation procedures.

• Collaborates with Clinical, Nursing, Admissions, and Revenue Cycle teams to ensure documentation validates medical necessity, level of care assessments, and reimbursement optimization.

• Creates enterprise KPI dashboards and reporting frameworks related to denials, overturn rates, authorization timelines, payer trends, reimbursement performance, length of stay management, and utilization efficiency.

• Analyzes trends, identifies gaps, and uncovers opportunities within utilization management processes, leading performance improvement initiatives to boost operational and financial results.

• Works alongside executive leadership on payer contracting strategies, authorization challenges, network access issues, and value-based care initiatives.

• Acts as an organizational authority on payer requirements, medical necessity criteria, utilization management regulations, and behavioral health reimbursement practices.

• Oversees the recruitment, onboarding, training, mentoring, performance management, and leadership development of enterprise UR leadership and staff.

• Conducts regular audits and quality assessments to ensure adherence to regulatory requirements, payer expectations, and organizational standards.

• Leads educational initiatives across the enterprise focused on documentation integrity, medical necessity criteria, payer trends, and best practices for authorization.

• Collaborates with Information Technology and EHR leadership to enhance utilization review workflows, reporting capabilities, automation prospects, and data integrity.

• Supports organizational growth initiatives, acquisitions, new program development, and expansion strategies through scalable utilization management processes.

• Participates in executive meetings, operational reviews, and strategic planning initiatives as a prominent organizational leader.

• Ensures the confidentiality of all company, departmental, patient, payer, and healthcare provider information.

• Reports enterprise risks, payer concerns, and operational obstacles to executive leadership, providing recommendations for resolution and mitigation.

⛳️ Requirements

• A Bachelor’s degree is mandatory.

• A Master’s degree in nursing, Healthcare Administration, Business Administration, or a related healthcare field is preferred.

• Clinical licensure is preferred (RN, LCSW, LPC, LMFT, or equivalent behavioral health licensure).

• A minimum of 7 years of progressive leadership experience in Utilization Review within behavioral health is required, ideally including large multi-site or enterprise oversight responsibilities.

• Previous experience in developing KPIs, reporting analytics, dashboards, and executive-level operational presentations is essential.

🏝️ Benefits

• Equal employment opportunities are provided without regard to race, color, creed, ancestry, national origin, ethnicity, sex, gender, sexual orientation, marital status, religion, age, disability, gender identity, genetic information, military service, or any other characteristic protected by applicable federal, state, or local law.

• Reasonable accommodations may be made for qualified individuals with disabilities.