Vice President, Operations - Case Management & Utilization Management

Shearwater Health•Nashville, TN

About The Position

About Shearwater Health: At Shearwater Health, we know that better patient outcomes are never achieved alone – especially when there aren’t enough hands to deliver care. That’s why we’ve built something different: a global team of clinicians helping solve one of healthcare’s most urgent challenges – the nursing shortage. By expanding the reach of care teams and reinforcing critical support systems, we bring clarity, compassion, and clinical expertise to the front lines of care. As the founder of the nation’s first Clinical Process Outsourcing (CPO®) model and a Great Place to Work®-certified company, we help the world’s top healthcare organizations work smarter – scaling their teams, strengthening care, and solving real problems every day. From clinical decision support to administrative tasks, our team of nearly 6,000 clinicians and process experts work across borders and time zones to help our partners focus on what matters most: delivering exceptional patient care. If you’re ready for your work to not just support care – but strengthen the system – join us. This is where clinicians become changemakers, and where nurses go further than they ever thought possible. Position Overview The Vice President, Operations for Case Management (CM) and Utilization Management (UM) is the enterprise leader responsible for operational strategy, financial performance, global delivery execution, organizational excellence and regulatory integrity across all CM and UM programs. This role oversees large-scale global teams, holds P&L accountability for the CM/UM business unit, ensures revenue growth, margin performance, scalable delivery operations, accreditation readiness, client satisfaction, and strong financial stewardship. The position serves as the senior client-facing executive and subject matter expert, guiding operational strategy and commercial growth across all global delivery sites. The Vice President partners closely with Quality, Training, Compliance, Business Excellence/Technology and Sales leaders to drive innovation, consistency, throughput and clinical rigor across all service lines.

Requirements

Active, unrestricted RN license required; compact or multi-state license preferred
Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, Business, or related field.
10+ years of progressive leadership in Case Management, Utilization Management, Care Coordination, Managed Care, or healthcare operations.
Experience leading multi-site or global operations in payer, provider, or RCM/clinical operations environments.
Deep knowledge of medical necessity review, clinical criteria, care coordination, care transitions and population health models.
Strong understanding of URAC/NCQA accreditation, CMS requirements and state regulatory frameworks.
Demonstrated success with P&L ownership, financial performance management, and scaling service delivery organizations.
Proven ability to lead clinical and operational teams, quality programs, and workforce development functions.
Strong executive presence, client-facing experience, negotiation skills, and ability to design complex operational solutions.
Experience with UM/CM platforms, EMRs, analytics tools, and collaboration platforms.
Ability to travel up to 50% to headquarters, client sites, and global delivery centers

Nice To Haves

Master’s degree preferred (MBA, MHA, MSN, or related).
CCM – Certified Case Manager
ACM-RN – Accredited Case Manager (Nursing)
CPUM – Certified Professional in Utilization Management
CPHQ – Certified Professional in Healthcare Quality
Lean/Six Sigma certification
Exposure to automation, AI-supported workflows and digital health enablement preferred

Responsibilities

Strategic & Operational Leadership Define the enterprise UM/CM strategy, operating model, financial goals, UM/CM growth objectives and annual performance roadmap across delivery sites.
Oversee all UM and CM operations ensuring compliance with state, federal, and accreditation requirements (URAC, NCQA, CMS, state DOIs)
Establish and monitor performance against SLAs, KPIs and clinical quality benchmarks, including medical necessity accuracy, turnaround times and case management outcomes.
Own P&L performance including forecasting, budgeting, revenue realization, pricing strategy, and margin optimization.
Drive operational standardization and scalable workflows across domestic and international delivery centers.
Partner with Workforce Planning to optimize staffing models, productivity targets, and global workforce deployment.
Lead a culture of accountability, operational excellence, data-driven decision-making, and continuous improvement.
Client Engagement, Growth, and Commercial Oversight Serve as executive sponsor for strategic CM/UM accounts, ensuring exceptional service delivery and participating in governance meetings, QBRs and performance reviews.
Lead operational solution design, pricing, staffing models, implementation planning, and readiness for new or expanding programs.
Represent UM/CM operations in RFP responses, finalist presentations, due diligence reviews and accreditation discussions.
Partner with Sales and Clinical Quality & Training teams to enhance value propositions and market differentiation and expansion in CM/UM services.
P&L Ownership and Operational Excellence Direct daily global operations for CM and UM programs, ensuring performance against SLAs, KPIs, productivity, timeliness, and quality benchmarks.
Implement operational dashboards, forecasting models, and performance systems to ensure program efficiency and cost effectiveness.
Partner with workforce planning to ensure effective capacity management, and operational scalability across all delivery geographies.
Oversee throughput, case review efficiencies, authorization turnaround times, and case management workflow optimization.
Quality, Compliance, and Risk Partner with the Clinical team to drive enterprise quality frameworks, including audit methodology, accreditation/compliance standards, corrective action programs, and regulatory readiness
Ensure full compliance with payer, provider, and regulatory requirements across CM/UM operations.
Ensure regulatory turnaround time (TAT) requirements are consistently met and proactively managed.
Leverage analytics to strengthen continuous quality improvement, clinical integrity, and operational performance.
Monitor, identify, and mitigate operational and regulatory risks to ensure organizational stability and compliance.
People Leadership Lead, coach and develop senior operational leaders across global delivery sites.
Partner with Talent Acquisition to define role profiles and support structured interviewing processes to enable efficient, highâquality hiring.
Partner with Human Resources on organizational design, leadership development, talent mobility, and succession planning.
Build a highâperformance, dataâdriven culture across diverse, remote teams.
Technology, Business Excellence, and Innovation Partner with Technology and Business Excellence teams to implement workflow systems, automation, and clinical decision support tools that improve UM/CM throughput.
Champion continuous improvement initiatives aimed at reducing cost, improving turnaround times, and enhancing clinical appropriateness
Leverage analytics for operational forecasting, productivity improvement, quality trend analysis, and financial optimization.
Recommend enhancements to systems, tools, and processes to enable innovation and operational modernization.
Expand UM/CM capabilities to support emerging payer/provider needs: value-based care, risk adjustment intersection clinical programs, readmission reduction and complex care management.