Provides strategic leadership and enterprise oversight for Utilization Management review activities and initiatives
Accountable for executing UM strategy and driving sustained operational performance
Ensure effective alignment and integration of people, processes, and systems
Manage execution of meeting or exceeding clinical operation requirements by Federal, State, and Accrediting bodies
Collaborate to build necessary divisional market infrastructure and matrix support
Develop and monitor UM policies, procedures and goals as needed to align with regulatory and accreditation requirements

Bachelor's Degree required
Master's Degree in Business or Health Care preferred
Ten (10) years of experience in managed care or clinical operations required
Five (5) years of leadership/management experience 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
Ability to influence goals and metrics across a heavily matrix organization
Current, unrestricted license in the state of practice as a Registered Nurse (RN) required
Compact Registered Nurse (RN) license preferred
Managed Care, Utilization Management Case Management and/or Quality Improvement certification preferred

Associate Vice President – Utilization Management

Key skills