Associate Vice President, Utilization Management

CareSource•Dayton, OH

1d•Onsite

About The Position

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.

Requirements

Bachelor's Degree required
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
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
Current, unrestricted license in the state of practice as a Registered Nurse (RN) required

Nice To Haves

Master's Degree in Business or Health Care preferred
Equivalent years of relevant work experience may be accepted in lieu of required education
Compact Registered Nurse (RN) license preferred
Managed Care, Utilization Management Case Management and/or Quality Improvement certification preferred

Responsibilities

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.