JOB SUMMARYThis role drives the execution and continuous optimization of Highmark's Utilization Management operations, leading its transformation for top-tier performance and efficiency. The incumbent ensures operational excellence, manages large-scale operations with aggressive process improvements and technology use, translating strategic vision into efficient, quality, and cost-effective delivery. The incumbent leads a massive operational organization, implementing and mastering industry-best practices in Lean Six Sigma and highly progressive global workforce models. This position champions continuous improvement, optimizes staffing, and builds strong partnerships across the health plan to perfect workflows, reduce costs, and develop the workforce, while maintaining clear accountability and financial oversight.
ESSENTIAL RESPONSIBILITIES- Held acutely accountable for consistently achieving and comprehensively reporting on a suite of aggressive operational targets, intrinsically linked to the overall financial health of UM, while maintaining budgetary responsibility and authority for UM operational expenditures. Ensure highly accurate outcomes by implementing stringent controls and eliminating errors in key processes utilizing technological advancements to attain optimal results and efficiency.
- Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
- Drive and embed unparalleled operational performance across all UM functions, emphasizing quality, speed, and critical unit cost reduction. Instill and champion Lean Six Sigma principles, methodologies, and advanced tools throughout the operational fabric, cultivating a pervasive culture of continuous improvement, waste elimination, and Six Sigma-level process control. Provide detailed oversight and rigorous governance of all operational processes within medical UM.
- Spearhead initiatives for operational unit cost reduction, leveraging efficiency gains, pervasive automation, and optimal workforce strategies to minimize expenses per unit of output.
- Design, implement, and meticulously manage programs to cultivate an exceptionally engaged, high-performing, and highly productive global operational workforce. Determining and optimizing staffing sources and identifying opportunities for global enhancements for maximum operational effectiveness. Expertly optimizing the intricate offshore vs. onshore mix, spearheading progressive offshore management strategies for maximal global staff optimization and resource leveraging.
- Forge and nurture exceptionally robust relationships with critical operational upstream and downstream partners across the entire health plan. This includes active, hands-on collaboration and process integration with Claims, Appeals, Provider Relations, and Member Services, ensuring holistic workflow, seamless handoffs, integrated processes, and end-to-end operational synergy and problem-solving across all touchpoints. Collaborate closely with the Highmark health plan's Chief Medical Officer to achieve best-in-class utilization management quality outcomes, leveraging benchmark metrics.
- Other duties as assigned or requested.
EXPERIENCERequired- 7 years of experiences in the Health Insurance Industry, with extensive and proven experience in payer operations management.
- 5 years of experience with Management or leadership role
- 5 years of proven, hands-on expertise in the successful implementation and leadership of Project Management and Lean Six Sigma, OpEx, or similar advanced continuous improvement methodologies at enterprise scale.
- 5 years of experience in Senior Operational Leadership within a large-scale operations environment, with direct and verifiable accountability for efficiency, operational performance, and critical financial delivery.
Preferred- 3 years with demonstrable, in-depth experience in complex demand and capacity management, sophisticated workforce optimization (including global offshore models), and expert resource allocation within large operational environments.
- 3 years of documented track record of successfully leveraging advanced technology for significant operational improvement, widespread automation, and substantial unit cost reduction.
- 3 years of extensive experience managing complex multi-vendor relationships (e.g., BPO providers) with exacting performance and financial accountability.
SKILLS- Ability to lead and manage process and integration initiatives with core health plan operational areas like Claims and Appeals.
- Deep understanding of Medical Management operations (even if for non-clinical roles), understanding the clinical-administrative interfaces.
EDUCATIONRequired- Bachelor's degree in Operational Excellence, Business Administration/Management, Clinical Programs, or related field or relevant experience and/or education as determined by the company in lieu of bachelor's degree.
Preferred- Master's degree in Operational Excellence, Business Administration/Management, Clinical Programs, or related field
LICENSES or CERTIFICATIONSRequiredPreferred- Lean Sigma Balck Belt or Master Black Belt
- Agile Scrum Master
- PMP Certification
Language (Other than English):Travel Required:PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition Type Physical work site requiredDisclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
