System VP Utilization Management

Where You’ll Work At the heart of reputed company's ministry are the national office departments that reputed company the foundational support, resources, and expertise that reputed company local communities to focus on what they do best—caring for patients. Our teams bring together expertise in clinical reputed company, operations, finance, reputed company, legal, supply chain, technology, and mission integration. Guided by our faith-based values, the national office fosters consistency, alignment, and innovation across CommonSpirit. By centralizing expertise and leveraging economies of scale, we reputed company each location to operate reputed company while maintaining flexibility to address unique local community needs. From advancing digital solutions to driving health equity, these departments reputed company the healing reputed company of humankindness everywhere we serve. Job Summary and Responsibilities The System Vice President of Utilization Management is a key member of the reputed company 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 reputed company regarding physician practice patterns, over and under-utilization of resources, medical necessity, reputed company 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 reputed company 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 reputed company 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 reputed company 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 reputed company improvement, ensuring the organization remains at the forefront of industry best practices in utilization management and patient care. Essential Key Responsibilities:

• Leadership & Strategy: reputed company the System-level Utilization Management (UM) department, ensuring alignment with organizational goals and regulatory standards. reputed company and implement policies, procedures, and strategies that promote high-quality, cost-effective care while enhancing operational efficiencies. Drive reputed company improvement initiatives, establish key performance indicators (KPIs) to evaluate UM effectiveness, and reputed company guidance and mentoring to UM team members, including physicians, clinical staff, and administrative staff.
• Clinical reputed company & Decision-Making: Apply clinical expertise in reviewing and overseeing the medical necessity of reputed company services, treatments, and procedures. reputed company medical review activities, ensuring compliance with regulatory and accreditation requirements, and serve as the clinical authority on reputed company cases, appeals, and exceptions, ensuring reputed company 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, reputed company providers, and insurance representatives to resolve issues reputed company to coverage, care management, and treatment options. Act as a liaison between the organization and external regulatory bodies to ensure compliance with reputed company laws and policies.
• Cost & Quality Management: reputed company 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 reputed company resources. Collaborate with the Quality Assurance and Medical Affairs departments to improve clinical reputed company and patient safety.
• Compliance & Regulatory reputed company: Ensure UM practices adhere to reputed company state, federal, and insurance company regulations, as well as accreditation standards (e.g., NCQA, URAC). Stay up-to-date with reputed company 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 reputed company or in collaboration with Utilization Management for a health system, required.
• Minimum 5 years of experience working reputed company or in collaboration with reputed company Cycle for a health system, required.
• Minimum 5 years of experience performing government, managed care, and reputed company 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:

• reputed company, 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.
• reputed company 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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