Job Summary and Responsibilities

The System Vice President of Utilization Management is a key member of the healthcare organization's leadership team and is charged with meeting the organization's goals and objectives for assuring the effective, efficient utilization of health care services. This role will be an expert on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, compliance with governmental and private payer regulations, and appropriate physician coding and documentation requirements.

Under direction of the System Senior Vice President of Clinical Regulatory and Revenue Enhancement, this role will have responsibility and accountability for creating, implementing, and leading an integrated system-wide utilization management program which includes comprehensive denials management. This role is critical to maintaining the organization's competitive position in the healthcare market and ensuring compliance with regulatory requirements. This role will also be responsible for developing and implementing innovative strategies to meet the evolving needs of the healthcare industry and driving improvements in quality, patient satisfaction, and operational efficiency.

As a member of the senior leadership team, the System Vice President of Utilization management will contribute to high-level organizational decision-making, working closely with other executives and clinical leaders to align utilization management practices with overall business goals. This role will also be expected to drive a culture of continuous improvement, ensuring the organization remains at the forefront of industry best practices in utilization management and patient care.

Essential Key Responsibilities:

• Leadership & Strategy: Lead the System-level Utilization Management (UM) department, ensuring alignment with organizational goals and regulatory standards. Develop and implement policies, procedures, and strategies that promote high-quality, cost-effective care while enhancing operational efficiencies. Drive continuous improvement initiatives, establish key performance indicators (KPIs) to evaluate UM effectiveness, and provide guidance and mentoring to UM team members, including physicians, clinical staff, and administrative staff.
• Clinical Oversight & Decision-Making: Apply clinical expertise in reviewing and overseeing the medical necessity of healthcare services, treatments, and procedures. Lead medical review activities, ensuring compliance with regulatory and accreditation requirements, and serve as the clinical authority on complex cases, appeals, and exceptions, ensuring decisions are made based on medical necessity and best practices.
• Collaboration & Communication: Collaborate with senior leadership, clinical teams, and external stakeholders to promote a coordinated approach to utilization management. Communicate effectively with physicians, healthcare providers, and insurance representatives to resolve issues related to coverage, care management, and treatment options. Act as a liaison between the organization and external regulatory bodies to ensure compliance with healthcare laws and policies.
• Cost & Quality Management: Develop and implement cost-control strategies that reduce unnecessary medical expenses while maintaining high-quality care. Monitor utilization trends and identify opportunities for cost savings through appropriate management of healthcare resources. Collaborate with the Quality Assurance and Medical Affairs departments to improve clinical outcomes and patient safety.
• Compliance & Regulatory Oversight: Ensure UM practices adhere to all state, federal, and insurance company regulations, as well as accreditation standards (e.g., NCQA, URAC). Stay up-to-date with healthcare regulations, industry trends, and best practices in utilization management.

Job Requirements

Education & Experience:

• Master's or Post Graduate Degree with graduation from an accredited medical school required.
• Minimum 10 years of experience working with health care delivery systems, required.
• Minimum 5 years experience in physician advisory, required
• Minimum 5 years of experience working within or in collaboration with Utilization Management for a health system, required.
• Minimum 5 years of experience working within or in collaboration with Revenue Cycle for a health system, required.
• Minimum 5 years of experience performing government, managed care, and commercial appeals required.
• Minimum 7 years of experience in a director level, or equivalent leadership role, required.
• Prior VP and/or CMO experience greater than 3 years, preferred

Licensure & Certifications:

• Current, valid state license as a physician.
• Member of the American College of Physician Advisors (ACPA) preferred.
• Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) preferred.
• Physician Advisor Sub-specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) preferred.

Required Minimum Knowledge, Skills & Abilities:

• Demonstrated knowledge of nationally recognized medical necessity criteria.
• Capable of working independently with a high level of performance in a rapidly changing, fast paced environment.
• Current knowledge of federal, state and payer regulatory and contract requirements.
• Previous Physician Advisor/Care Management or equivalent experience. Excellent communication skills - both verbal and written.
• Strong interpersonal communication skills.

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