VP of Utilization Management (RN)

Location: Boston, MA
Date Posted: 08-01-2018
Vice President of Utilization Management (RN) - Managed Care
Boston, MA
VP of Utilization Management Job Summary: 
  • Responsible for setting the strategic direction, planning, budgeting and coordination and oversight of all health plan utilization management operations consistent with the integrated health delivery model and payer functions.
  • Responsible for cross-functional integration of utilization management program operations with core organization-wide business functions, including care management and care delivery, claims and member services, compliance, quality and contracting/network management.
  • Provide leadership for all utilization management and clinical fulfillment functions. 
  • Develop and implement the business plan, strategies, and operational plans to ensure high quality, consistent delivery of utilization management and clinical fulfillment functions. 
  • Develop metrics to monitor and manage the performance of all utilization management functions and hold key leaders accountable for performance on such measures. 
  • Ensure controls are established to maintain compliance with all contract requirements, state and federal regulatory requirements and all applicable accreditation standards 
  • Leads continuous development and improvement of policies, protocols, clinical guidelines and aligned business practices across utilization management and fulfillment functions. 
  • Facilitates preparation for the Utilization Management Committee on behalf of the SVP Clinical Operations and the Chief Medical Officer. 
  • Leads the development and achievement of annual medical expense targets by service type, region, care model, etc. 
  • Provides leadership for the development of external partnerships with hospitals, SNFs, primary care practices and external provider partners. 
VP of Utilization Management  Background Profile: 
  • Requires a valid, unrestricted state Registered Nurse (R.N.) license & Bachelor of Science in Nursing (B.S.N.) or related field; Master’s Degree in Nursing, Healthcare Administration or related field preferred.
  • Requires around 3-6 years’ clinical nursing experience; preferably in an acute care hospital setting.
  • At least 10 years’ experience with medical management (CM/UM/QM) at a Managed Care Organization, such as Health Plan, IPA, Medical Group, or HMO.
  • Requires 5-7 years previous health plan management experience, in roles of increasing responsibility.
  • Significant Medicare and Medicaid managed care experience with direct responsibility for clinical operations  including prior authorization, utilization management operations
  • Experience with strategic planning, implementing, and evaluating clinical programs.
  • Knowledge of utilization management, quality improvement, discharge planning, and cost management.
  • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
  • Excellent verbal and written communication skills, as well as exceptional critical thinking skills.
  • Possess very strong coaching/counseling skills including the ability to function as a mentor to management and employees.
  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.

480.646.3275 (CALL – TEXT – FAX)
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