Description

The Vice President, Utilization Management serves as the executive leader responsible for enterprise strategy, performance optimization, and value-based resource management across Oceans Healthcare. This role establishes the organizational vision for utilization management, care progression, and reimbursement optimization and aligns clinical, operational, and financial stakeholders to support system growth, regulatory excellence, and sustainable margin performance.

The VP moves the organization beyond utilization review as a compliance function to a strategic clinical and financial operating discipline. The position partners with Vice President, Strategic Payer Relations & Performance, medical leadership, and revenue cycle leadership to improve payer performance, patient access, and reimbursement integrity while enhancing patient outcomes and physician engagement.

This executive will design and lead system-wide initiatives that integrate care coordination, documentation integrity, payer strategy, and operational workflows to ensure the organization delivers the right care, at the right level, at the right time, in the most appropriate setting.

Essential Functions:

1. Establish the enterprise vision and long-term strategy for utilization management.
2. Serve as the executive subject matter expert advising the CEO, COO, CFO, CMO, and Revenue Cycle leadership on utilization management payer trends and regulatory risk
3. Provide executive utilization management reporting and performance analytics to leadership and the Board.
4. Translate organizational growth goals into operational utilization management initiatives.
5. Align hospital operations, medical staff leadership, and revenue cycle functions to system priorities.
6. Lead change management for system-wide clinical and operational initiatives affecting patient flow, admissions, and payer performance.
7. Develop and execute strategies to improve net patient revenue, reimbursement capture, and denial prevention across all facilities.
8. Identify financial leakage within patient status, length of stay, and authorization workflows and implement corrective strategies.
9. Oversee enterprise denial management strategy and executive-level payer escalation processes.
10. Partner with contracting and revenue cycle leadership to influence payer negotiations using data, trends, and operational leverage.
11. Collaborate with medical staff leadership to improve physician engagement, peer-to-peer review success, and appropriate level-of-care determinations.
12. Lead initiatives connecting UM, Case Management, CDI, and Quality to improve clinical outcomes and regulatory compliance.
13. Ensure regulatory readiness and accreditation performance across all facilities.
14. Establish enterprise KPIs and predictive analytics to monitor performance, payer risk, and resource utilization. Oversee development of executive dashboards and decision-support tools.
15. Use data to drive operational and physician behavior change.
16. Evaluate and implement technology platforms supporting utilization management and care coordination.
17. Provide executive oversight of Corporate and System Utilization Management leadership.
18. Develop leadership capability among facility-level directors and managers.
19. Build standardized workflows and governance structures across all facilities.
20. Lead cross-department committees involving operations, medical staff, compliance, and revenue cycle.
21. Performs other duties as assigned

Requirements

Education / Experience:

• Master's Degree in Healthcare Administration, Nursing, Business Administration, or related field preferred.
• 10+ years of progressive healthcare leadership experience
• Multi-facility or health system leadership required
• Experience working directly with physicians and senior executives
• Demonstrated success improving reimbursement, denial reduction, or operational throughput
• Experience with behavioral health or post-acute healthcare systems preferred
• Experience with payer negotiations, value-based care, or risk-bearing models

Skills / Abilities:

• Enterprise strategic thinking
• Executive communication & influence
• Financial acumen
• Change leadership
• Physician relationship management
• Data-driven decision making
• Regulatory & compliance expertise

Work Environment:

Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere. Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.