Overview
Oversees and manages the utilization management and medical management functions within VNS Health. Possesses deep expertise in healthcare operations, utilization management processes, prior authorization, regulatory requirements, and operational process improvement. Works closely with cross-functional teams, including medical directors, nurses, care managers, Provider Network Management, Claims, Compliance, Quality, and administrative staff, to ensure efficient and effective utilization of healthcare resources. Ensures the health plan meets the Center for Medicare Services (CMS), State and other external regulations for all medical management and member services areas. This role has a strong focus on process transformation, prior authorization operations, policy development and implementation, documentation standards, regulatory compliance, and continuous improvement. Works under general supervision. What You Will Do:
- Designs and implement utilization management programs, policies, and procedures to ensure appropriate utilization of healthcare services while maintaining high-quality patient care outcomes.
- Leads the evaluation, redesign, and continuous improvement of utilization management and prior authorization processes to improve operational effectiveness, consistency, compliance, and accountability.
- Drives initiatives from assessment and design through implementation, adoption, measurement, and sustained operational performance.
- Oversees the utilization review process to evaluate the medical necessity, appropriateness, and efficiency of healthcare services rendered. This includes reviewing medical records, claims data, and other relevant information to make utilization decisions.
- Oversees Medical Management functions for utilization management (UM) for Inpatient, Outpatient, and rehab/skilled services for members in VNS Health Plans products.
- Provides strategic and operational leadership for prior authorization processes, ensuring policies, procedures, workflows, and documentation standards are aligned with current CMS and other applicable regulatory requirements.
- Translates regulatory and policy requirements into clear, executable operational processes and ensures teams understand both the requirements and the rationale behind them.
- Identifies gaps in documentation, workflow, controls, or accountability that may create regulatory, compliance, operational, or financial risk and develops appropriate remediation plans.
- Monitors changes in CMS and other regulatory requirements and leads timely updates to utilization management policies, procedures, documentation standards, and operating processes.
- Provides leadership, guidance, and supervision to the utilization management team, including nurses, case managers, and administrative staff. Set performance goals, conduct regular performance evaluations, and provide coaching and mentoring to ensure team members meet objectives and deliver high-quality work.
- Builds organizational capability by teaching, coaching, and developing leaders and staff in utilization management processes, prior authorization requirements, documentation standards, regulatory expectations, and operational best practices.
- Serves as a knowledgeable and credible subject-matter resource while fostering a culture of accountability, learning, consistency, collaboration, and continuous improvement.
- Ensures compliance with all applicable regulatory requirements, including those set by government agencies, accreditation bodies, and health plans. Monitor changes in regulations and update policies and procedures accordingly.
- Ensures ongoing audit readiness by maintaining strong utilization management processes, documentation, controls, and regulatory compliance practices.
- Collaborates with the quality management department to identify areas for improvement in the utilization management process. Implement quality improvement initiatives, monitor performance metrics, and drive continuous improvement efforts.
- Leads root-cause analysis of operational and process issues and develops measurable action plans to improve performance, compliance, timeliness, documentation quality, and execution.
- Fosters effective working relationships with various departments, including medical staff, claims, provider network management, and finance. Collaborate with these departments to streamline processes, resolve issues, and optimize resource utilization.
- Partners closely with Provider Network Management to develop, interpret, communicate, and operationalize utilization management and prior authorization policies that impact providers.
- Provides direction and subject-matter expertise to cross-functional partners when developing or modifying utilization management policies, procedures, workflows, and operating standards.
- Develops and monitors KPIs and operational metrics related to utilization management, prior authorization, documentation quality, regulatory compliance, timeliness, workflow effectiveness, and operational performance.
- Stays up-to-date with changes in healthcare policies, reimbursement models, and industry best practices related to utilization management. Applies knowledge to inform decision-making and enhance operational efficiency.
- Collaborates with Medical Director to coordinate appropriate utilization to meet member needs. Co-chairs UM/CM committee and attends QIC committee meetings.
- Oversees the development and implementation of long-range strategic plans, goals and objectives. Ensures that strategic plans, goals and financial targets are implemented within the business units to support the growth and profitability of the plan.
- Translates strategic and regulatory priorities into executable operational plans with clear governance, ownership, accountability, controls, and performance measures.
- Oversees the consistent application and operationalization of clinical criteria, utilization policies, medical policies, and regulatory requirements across utilization management functions.
- Oversees quality of care using benchmark and objective data, including but not limited to member health outcomes, satisfaction survey results, utilization metrics, CAHPS results, and HEDIS/Stars performance
Qualifications
Licenses and Certifications:
- Clinical licensure is not required. Registered Nurse or other clinical licensure may be preferred based on the candidate's overall background and experience preferred
- Candidates who hold an RN license outside of New York State may be considered and may obtain New York State licensure after hire
Education: Bachelor's Degree in healthcare administration, business administration, healthcare management, nursing, or a related field required Master's Degree in healthcare administration, business administration, healthcare management, nursing, or a related field preferred Work Experience:
- Minimum 8 years of progressive experience in utilization management, medical management, prior authorization, healthcare operations, or a closely related managed care function required
- Demonstrated people leadership experience, including responsibility for coaching, developing, training, and managing teams required
- Strong knowledge of prior authorization policies, procedures, workflows, documentation requirements, and operational controls required
- Strong knowledge of CMS requirements impacting utilization management and prior authorization required
- Demonstrated ability to interpret regulatory, policy, and operational requirements and translate them into effective processes and procedures required
- Strong understanding of healthcare reimbursement models, including fee-for-service and value-based care required
- Excellent analytical and problem-solving skills, with demonstrated ability to identify process gaps, determine root causes, develop practical solutions, and drive measurable improvement required
- Proven track record in driving process improvement initiatives and achieving measurable results required
- Demonstrated experience leading significant operational or process change within a complex healthcare or managed care environment required
- Experience developing, implementing, or improving utilization management and/or prior authorization policies, procedures, workflows, and operating controls required
- Experience partnering cross-functionally with Provider Network Management, Claims, Compliance, Quality, Medical Management, and other operational stakeholders required
- Strong leadership abilities, including the ability to inspire and motivate a diverse team required
- Exceptional communication and interpersonal skills, with the ability to collaborate effectively with internal and external stakeholders required
- Ability to establish credibility through depth of subject-matter expertise while remaining open to learning, collaboration, and continuous improvement required
Pay Range
USD $193,600.00 - USD $258,200.00 /Yr.
About Us
VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.
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VNS Health
Oct 29, 2026