Apply on Employer Site

Medasource · 7 hours ago

VP, Utilization Management

United States

Full-time

Remote

Director/Executive

$240K/yr - $280K/yr

10+ years exp

Medasource is a healthcare payer client seeking a Vice President of Utilization Management. The role involves leading a transformation of the Utilization Management process to enhance experiences for members, providers, and internal teams while ensuring compliance and performance metrics are met.

Health CareMedical

Growth Opportunities

Hiring Manager

Haley Daprile

Responsibilities

Define end‑to‑end UM intake, prior authorization, concurrent review, discharge planning linkages, post‑service/retrospective review, appeals & grievances, denials management, peer review governance, provider escalation pathways

Build the insourcing plan and vendor strategy with clear milestones

Ensure UM policies and criteria follow Traditional Medicare coverage (NCD/LCD) where established; when not established, create transparent, evidence‑based internal criteria

Stand up/lead the UM Committee and annual policy review cadence

Establish a UM scorecard and governance (weekly ops rhythm; monthly exec steering): PA turnaround (standard/expedited), avoidable denials/appeals, overturn %, provider escalations, member/provider CAHPS touchpoints, admin measure improvements, inter‑rater reliability, call center ops (ASA/abandonment)

Design UM to enable provider‑sponsored performance and care coordination; reduce administrative burden through rules engines and smart auto‑approvals where appropriate

Sponsor the DMAIC execution already underway (30 days in): validate current‑state maps, remove bottlenecks, deploy standard work, and lock in controls

Define build/buy for UM tech (portal, rules engine, evidence library, work queue, analytics)

Set principles for the use of algorithms/AI (assistive, not determinative) consistent with CMS guidance

Hire and coach a hands‑on Director and core team (clinical ops, UM analytics, provider relations/change)

Align incentives with KPIs; drive adoption across Health Plan & Alliance

Qualification

Utilization ManagementMedicare AdvantageLean Six SigmaGovernance & MetricsTransformation LeadershipExecutive PresenceCoaching Skills

Required

10–15+ years in payer/provider‑sponsored health plans, with 7+ leading UM across product lines; proven success standing up or insourcing UM

Depth in Medicare Advantage requirements (coverage parity with Traditional Medicare, prior auth limits, continuity of care, annual UM policy review/committee)

Track record building UM governance & metrics and passing NCQA/URAC‑aligned audits

Lean Six Sigma leadership (Green/Black Belt preferred); scaled DMAIC in clinical/admin workflows

Comfortable operating on‑site at high intensity during transformation; executive presence with CMO/CEO and provider leaders