AVP, Utilization Management

Ensemble Health Partners•Work at Home - Ohio - Other, OH

2d•$134,000 - $167,500•Remote

About The Position

The Assistant Vice President, Utilization Management provides senior operational leadership for utilization management programs, supporting enterprise strategies focused on regulatory compliance, clinical documentation integrity, and reimbursement optimization. This role partners closely with clinical, operational, and financial leaders to execute utilization management initiatives, reduce preventable denials, and improve care coordination. The AVP supports the execution of enterprise utilization management strategy, oversees day-to-day operational performance across assigned programs or service lines, and leads managers and senior leaders responsible for utilization review, authorization, and medical necessity processes. This role will include travel, up to 25%.

Requirements

Bachelor’s degree or equivalent combination of education and experience
Current RN license
10+ years of relevant experience including advanced knowledge of utilization management and healthcare reimbursement
5+ years of people leadership experience
Strong executive presence with the ability to project confidence, credibility and authority; able to remain calm & show decisiveness under pressure
Exhibits strong strategic and analytical skills with the ability to drive operational improvements
Ability to build and maintain relationships with key internal and external stakeholders
Ability to effectively lead diverse teams and influence change management in a complex healthcare operations environment
Effective communication skills with ability to clearly and succinctly convey information and ideas
Demonstrated advanced usage of AI, success in translating AI into Business outcomes, and the ability to move teams from experimentation to scale.

Responsibilities

Executes enterprise utilization management strategy aligned with organizational and regulatory requirements
Oversees operations including prior authorization, medical necessity review, and concurrent review processes
Ensures compliance with CMS, payer, and state regulatory requirements
Identifies and mitigates audit, compliance, and reimbursement risks
Monitors performance metrics including denial trends and utilization efficiency
Drives performance improvement initiatives based on data analysis
Collaborates with clinical, case management, and revenue cycle teams to improve documentation and reduce denials
Supports implementation and optimization of utilization management technologies and workflows
Leads and develops managers and operational leaders
Supports succession planning and organizational capability development
May be required to perform other job-related duties as requested.
Able to travel up to 25% of the time, any may include occasional international travel