This is a strategy, governance, and cross-functional leadership role. The AVP is not expected to directly manage day-to-day utilization management or care management operations but will partner closely with operational leaders to shape priorities, establish strategic direction, define performance expectations, evaluate outcomes, and support scalable execution across Medicaid markets.

This leader is accountable for integrating utilization and care management strategy into a cohesive enterprise approach that supports the right care, at the right time, in the right setting, for Medicaid members. The role connects insights from authorization activity, utilization patterns, claims, denials and appeals, care management engagement, care gaps, admissions, emergency department use, post-acute utilization, high-risk member needs, and provider practice variation to inform enterprise strategy and market-level action.

The AVP serves as a strategic liaison to Medicaid market leadership and partners across Clinical Operations, Population Health Management, Behavioral Health, Pharmacy, Care Management, Network, Finance, Actuarial, Quality, Analytics, Payment Policy, Payment Integrity, and SIU. The role aligns enterprise utilization, care management, and affordability strategies with market realities, advances scalable solutions, and ensures disciplined governance across a significant clinical and financial performance domain.

This role is open to a physician leader and also to other highly qualified clinical or healthcare executives with deep experience in Medicaid managed care, utilization management, care management, clinical strategy, medical cost management, and complex matrixed leadership.

Responsibilities

• Lead enterprise Medicaid utilization and care management strategy, including prior authorization strategy, Medicaid clinical policy governance, medical expense strategy, site-of-care optimization, provider practice variation, high-risk member strategy, and targeted affordability initiatives.
  
• Establish strategic direction, governance routines, performance expectations, and enterprise priorities for Medicaid utilization and care management, in partnership with operational leaders accountable for day-to-day execution.
  
• Oversee Medicaid care management strategy at the enterprise level to ensure programs are member-centered, data-driven, clinically effective, operationally scalable, and aligned with utilization, quality, access, regulatory, and affordability goals.
  
• Integrate utilization management and care management strategies to identify members with rising risk, complex needs, avoidable utilization, care gaps, and opportunities for earlier intervention, improved care coordination, and more appropriate site-of-care decisions.
  
• Use utilization, authorization, denial, appeal, claims, care management, quality, medical expense, and member risk data to identify strategic opportunities, evaluate program performance, and recommend actions that improve outcomes while responsibly managing total cost of care.
  
• Oversee Medicaid clinical policy governance and medical necessity criteria in partnership with clinical and operational stakeholders to ensure policies are evidence-based, clinically appropriate, operationally feasible, member-centered, and compliant with state and federal requirements.
  
• Partner with Clinical Operations, Care Management, Population Health, Behavioral Health, Pharmacy, and market leaders to modernize utilization and care management approaches, improve provider experience, support administrative simplification strategies such as gold carding, and ensure appropriate access to medically necessary care.
  
• Identify and prioritize major medical cost and utilization drivers, including high-cost utilization, specialty services, avoidable admissions, emergency department use, readmissions, post-acute care, transitions of care, site-of-care opportunities, gaps in care coordination, and unwarranted variation across markets.
  
• Advance strategic approaches that connect utilization insights to care management interventions, including improved referral pathways, transitions-of-care strategies, complex care management models, condition-specific interventions, and coordination for members with physical health, behavioral health, pharmacy, and social needs.
  
• Partner with Finance, Actuarial, Medical Economics, Analytics, and market leadership to establish executive scorecards, business cases, ROI frameworks, savings validation approaches, and performance management processes to track progress, quality impact, operational risks, and emerging opportunities.
  
• Partner with Medicaid clinical operations and market leadership to understand state-specific regulatory requirements, provider dynamics, local performance opportunities, care management requirements, population health priorities, and operational constraints. Support implementation of enterprise strategies with appropriate market flexibility and help scale leading practices across Medicaid markets.
  
• Serve as a strategic partner to Payment Policy, Payment Integrity, and Fraud, Waste, and Abuse teams to ensure Medicaid priorities, risks, and opportunities are incorporated into enterprise affordability and program integrity efforts. This includes identifying opportunities to improve payment accuracy, reduce avoidable waste, and strengthen stewardship of healthcare resources.
  
• Evaluate and shape strategy for selecting vendors and external partners supporting utilization management, care management, clinical decision support, affordability programs, population health interventions, and medical cost management capabilities. This includes developing business cases, defining outcome expectations, monitoring performance, and ensuring vendor activities align with clinical, operational, financial, compliance, contractual, quality, and member experience objectives.
  
• Provide strategic direction for programs that improve care transitions, reduce avoidable inpatient and emergency department utilization, support appropriate post-acute management, improve engagement of high-risk members, and strengthen coordination across providers, plans, and community-based resources.
  
• Ensure utilization and care management strategies support Medicaid regulatory expectations, health equity, access to care, whole-person health, quality performance, and the needs of medically and socially complex populations.

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Leadership Scope

The AVP reports to the VP, Medicaid Clinical Strategy and Affordability and will lead a team focused on strategy, governance, analytics-informed decision support, cross-functional alignment, and performance oversight. The role operates through a highly matrixed enterprise and market model and partners closely with leaders accountable for operational execution.

This leader will work across Clinical Operations, Care Management, Population Health Management, Behavioral Health, Pharmacy, Quality, Analytics, Finance, Actuarial, Network, Payment Policy, Payment Integrity, SIU, and Medicaid market leadership to align strategy, assess performance, identify opportunities, and support execution of scalable solutions.

The role is expected to provide enterprise strategic direction, establish governance and performance routines, support market alignment, and translate clinical, utilization, care management, and medical expense insights into actionable strategies. The AVP will be accountable for aligning cross-functional teams around shared goals for affordability, appropriate utilization, improved care coordination, quality outcomes, access, provider experience, and regulatory performance, while relying on operational partners to manage day-to-day program delivery.

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Required Qualifications

• 10+ years with leadership experience in Medicaid, managed care, utilization management, care management, clinical strategy, affordability, medical cost management, population health, or clinical operations.
• Licensed clinical background, including MD, DO, RN, NP, PA, PharmD, LCSW, or other relevant clinical credential.
• Demonstrated experience developing strategy, governance models, performance frameworks, and cross-functional initiatives in a complex healthcare environment.
• Strong understanding of Medicaid managed care, state and federal regulatory requirements, utilization management, care management models, clinical policy, provider delivery systems, member risk stratification, population health, and medical expense drivers.
• Demonstrated experience leading enterprise, segment-wide, or multi-market initiatives that influence total cost of care, utilization performance, care management effectiveness, quality outcomes, provider experience, member access, and regulatory performance.
• Proven ability to lead through influence in a complex matrixed environment and align senior stakeholders across market, clinical, operational, financial, actuarial, network, quality, analytics, population health, care management, and program integrity functions.
• Strong analytical capability with experience interpreting claims, utilization, authorization, denial, appeal, care management, provider variation, medical expense, quality, and savings performance data.
• Demonstrated ability to translate strategic priorities into executable roadmaps with measurable outcomes, governance routines, executive-level reporting, and performance monitoring.
• Strong executive communication, presentation, stakeholder management, and change leadership skills.
• Bachelor’s degree in a relevant field such as healthcare administration, nursing, public health, business administration, health policy, finance, or a related discipline, or equivalent relevant experience.

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Preferred Qualifications

• Physician leadership experience in managed care, Medicaid, utilization management, care management, medical policy, or clinical affordability.
• Advanced degree in a relevant field, such as medicine, nursing, public health, healthcare administration, business administration, health policy, or finance.
• Multi-state Medicaid managed care experience.
• Experience with enterprise strategy, operating model design, governance structure development, performance management, clinical affordability strategy, or large-scale transformation.
• Experience with prior authorization optimization, clinical policy governance, care management strategy, complex care management, transitions of care, population health management, gold carding, administrative simplification, site-of-care optimization, specialty cost management, payment policy, payment integrity, Fraud, Waste, and Abuse, or vendor strategy.
• Experience working with finance, actuarial, analytics, clinical, operational, care management, quality, and market teams to evaluate medical cost trend, utilization performance, care management outcomes, savings realization, and return on investment.
• Experience designing or leading strategies that connect utilization management, care management, population health, and medical expense performance to improve outcomes for complex Medicaid populations.

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Additional Information

This role provides focused executive leadership for the Utilization and Care Management Strategy pillar within the Medicaid Clinical portfolio. The AVP will be accountable for strategy development, strategy execution oversight, governance, market alignment, and cross-functional integration across utilization management, care management, clinical policy, affordability, quality, access, provider experience, and program integrity objectives.

The role is designed to shape enterprise direction and enable operational success, not to directly manage daily utilization management or care management operations. By connecting utilization insights with proactive care management strategy, this leader will help ensure Medicaid members receive clinically appropriate, coordinated, and effective care while advancing enterprise goals related to total cost of care, quality outcomes, regulatory alignment, and responsible stewardship of healthcare resources.

Scheduled Weekly Hours

Pay Range