Highmark Health · 15 hours ago
VP, Enterprise Utilization Management Strategy & Excellence
Pittsburgh PA, 15222, FAP, 5th Avenue Place
Full-time
Hybrid
Director/Executive
15+ years expHighmark Inc. is a leading health insurance organization, and they are seeking a VP for Enterprise Utilization Management Strategy & Excellence. This role is responsible for developing and executing the strategic vision for Utilization Management, ensuring compliance, operational excellence, and market leadership across all lines of business.
Health CareHospital
Responsibilities
Architect and rigorously execute the multi-year strategic roadmap for Utilization Management across Highmark’s 5M members, ensuring uncompromising alignment with Highmark’s Living Health strategy. Precisely position Highmark as a recognized leader in UM through ground-breaking practices and the highest quality for our members
Drive ambitious quality programs targeting exceptional decision accuracy, establishing a new standard of performance that surpasses current industry outcomes. Forge strategic partnerships and harness technological advancements to attain unparalleled reliability in UM processes and outcomes
Identify, cultivate, and seize opportunities to significantly grow and expand revenue through sophisticated Utilization Management Business Process as a Service (BPaaS) offering, thereby developing a robust, non-Highmark profit and loss capability for end-to-end UM management. This encompasses strategically engaging with and offering UM capabilities to external organizations, extending Highmark's reach
Lead critical cross-enterprise commitments, guaranteeing the delivery of exceptionally high-value, effective, and rigorously governed UM. Collaborate with all Highmark divisions to meticulously integrate and align UM strategies, technologies, and outcomes, impacting enterprise-wide financial performance and operational synergy at a significant scale
Define and champion the strategic direction for UM technology and automation, including spearheading the prioritization and funding of the platform and technology change enhancement backlog, and guiding transformative initiatives such as advanced automation for authorization data intake and streamlined auto-approval processes. Drive digital authorization management solutions to dramatically curtail reliance on archaic manual methods, setting the pace for digital adoption
Oversee Utilization Management across all business lines and states, ensuring processes and controls are in place to meet contractual SLAs and regulatory requirements for CMS, state Medicaid agencies and others
Establish the overarching strategic blueprint for a globally optimized UM workforce. This involves setting the strategic direction for optimizing complex offshore vs. onshore staffing models, overseeing sophisticated demand forecasting methodologies, and ensuring long-term staff allocation strategies meticulously align with profound transformational goals. Develop and foster a holistic framework for enterprise-level employee engagement initiatives across the vastly evolving organization, affecting hundreds to thousands of employees
Design, implement, and rigorously oversee the strategic performance framework for Utilization Management, defining granular critical success metrics to gauge transformational impact, validate market leadership, and quantify the realization of monumental strategic initiatives that redefine core business functions
This role provides executive leadership for direct reports and the broader UM organization, contributing to hiring, talent development, succession planning, and performance management; with the aim to cultivate a strong leadership team capable of executing long-term strategies with significant business impact
Other duties as assigned
Qualification
Required
15+ years in the Health Insurance Industry, demonstrating a profound understanding of payer operations and the broader healthcare ecosystem, ideally at a large, complex organization
10+ years in Strategic Operational Planning, inclusive of spearheading successful, large-scale, enterprise-wide organizational transformations that have significantly altered market position or financial outcomes
10+ years in a senior Operational Leadership role within a large-scale, intricate organization, evidencing mastery in leveraging levers for monumental efficiency and exponential scale
10+ years of direct healthcare cost containment experience in Payment Integrity, Claims, or Utilization Management experience
Proven, hands-on experience in business development, market expansion, or managing significant P&L responsibilities for complex service offerings
Demonstrable track record of leading and orchestrating enterprise-wide change initiatives and driving transformative process improvement methodologies at the highest executive level
Bachelor's degree in Nursing, Health Plan Administration or Business Administration/Management
Preferred
5+ years in a dedicated technology leadership role, or substantial executive experience overseeing technology-driven transformation as a primary strategic mandate for a large organization
5+ years in quality improvement initiatives at large scale organizations inclusive of end to end reform of operating model redesign to maximize speed, quality, and cost of operations
3-5 years of Medicaid Experience preferred
2-5 years in technology
Experience managing Medicaid and clinical teams
PMP or Lean Six Sigma Master Black Belt certification is highly preferred, evidencing a commitment to structured strategic execution and transformational quality leadership
Company
Highmark Health
Highmark Health is an integrated health care delivery and financing network.
10001+ employees
H1B Sponsorship
Highmark Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (38)
2024 (34)
2023 (55)
2022 (75)
2021 (54)
2020 (58)
Funding
Current Stage
Late StageTotal Funding
$6.75MKey Investors
Henry L. Hillman FoundationRichard King Mellon Foundation
2025-06-11Grant· $1.75M
2021-05-10Grant· $5M
Leadership Team
David Holmberg
President and Chief Executive Officer
Karen Hanlon
Executive Vice President, Chief Operating Officer
Recent News
Seattle TechFlash
2025-12-29
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