Vice President Utilization Management Operations

October 8, 2020
Philadelphia, PA
Job Type


Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at


The VP, Utilization Mgt Operations is responsible for the oversight, management and optimization of policy and execution for Utilization Management operations, meeting all contractual and compliance requirements. Participates in the development, implementation and maintenance of all programs to ensure that patient care maximizes quality and continuity by utilization of appropriate resources and alternatives to inpatient care within the parameters of health plan benefits and established contracts. Ensures consistency and standardization of the application of these healthcare delivery programs and the integration of these programs within the integrated care model. .  This leader will be responsible for new business RFPs and implementations.

The VP, UM operations  will identify opportunities for next best actions to improve processes and lower costs.   This leader will apply expertise in developing and utilizing key performance indicators to identify and investigate complex problems in various health care domains across several problem spaces. This leader will also deliver results on high-impact projects collaborating with various stake holders.

A successful leader will perform well in a fast-paced environment, will have an operational mindset with attention to detail, and will focus on identifying value to challenging business problems.  This position requires strong business acumen, exceptional communication skills, and the ability to make complex concepts simple and easy to understand.

Key responsibilities:

  • Oversee effective use of prior authorizations, policies, and benefits to ensure consistent, effective and efficient delivery to members while meeting regulations and internal financial objectives.
  • Review periodic reports (financial/utilization/services) to analyze trends, identify opportunities and ensure consistent deployment of , accurate data according to established polices & procedures across enterprise and market teams.
  • Ensure alignment to evidence based and best practice across functional areas of responsibilities and associated strategies are deployed across the Enterprise, Markets, and Products.
  • Initiates organizational and system changes to improve departmental staffing efficiency and effectiveness, and program outcomes within the markets.
  • Monitors performance metrics across LOBs and assures that appropriate action is taken to address performance opportunities consistent with enterprise policies.
  • Oversees a multidispinary team consisting of Medical Directors, Corporate Directors, and Pharmacy Directors.
  • Identify long-range, competitive strategies for UM, policy, and member benefits.
  • Partner with medical directors, enterprise, and market leaders in the development of best practices and shared learnings.
  • Maintains consistent program implementation and staffing across all LOBs.

Education/ Experience:

  • Master's Degree (Business or Healthcare) or equivalent work related experience.
  • Registered Nurse Licensure is preferred.
  • 10 or more years Progressive management experience (including staff management) in a managed care environment.
  • Experience with Managed Medicaid programs highly desirable.
  • Management experience with Quality programs, Case Management and Utilization management programs.
  • Experience in UM program design, implementation or healthcare operations Should include experience in setting, communicating and implementing strategic direction.

Other Skills:

  • Demonstrable history of success in managing clinical programs in Medicaid and/or Medicare managed care organizations.
  • Strong business acumen and an operational mindset.
  • Strong oral, written and interpersonal communication skills.
  • Clinical data analysis and trending skills.
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