VP, Utilization Management

Job Number6888Workplace Type:Fully RemoteOrange,California

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

This job is responsible for the provision of leadership, direction, oversight, and operations management for the Organization's Utilization Management (UM) functions across all markets for AHP. The incumbent interprets key performance metrics to develop plans, mobilize the work force, and achieve the Organization's UM outcomes relative to the Triple Aim (improved population health, improved experience of care, and lower healthcare costs). Accountable for the strategic and operational excellence of the UM function within Clinical Services including administrative and care cost initiatives, system development and delivery of high-quality outcomes, compliance with all state and federal regulations that affect UM activities and executive level reporting and communication as needed.

This position builds and maintains strong collaborative partnerships with key partners in the Clinical Services organization including Care Management, , Medical Management, Quality, Appeals & Grievance, Pharmacy, and Provider/ IPA relationshipto identify, develop, implement, and monitor performance metrics related to UM Operations. This position reports to senior Health Plan Medical Director.

General Duties/Responsibilities:

(May include but are not limited to)

• Perform management responsibilities to include but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Responsible for maintaining appropriate staffing ratio to ensure optimal performance for the department.

• Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary;

• Responsible for and manage UM department budget.

• Participate in strategic planning and in the establishment of strategic directions and goals for all clinical services operations to achieve key performance metrics

• Accountable for achieving established outcomes goals relative to UM operations

• Build alliances across the business and clinical leadership teams with the end objective of a collaborative, efficient and viable operating model.

• Innovate and implement new or revised models for the Organization's UM operations functions in response to evolving trends in healthcare delivery and/or emerging models of care.

• Build relationship with external vendors and medical group leadership in order to manage performance metrics, collaborate on issues and affect outcomes.

• Participate in or lead work groups/meetings to implement new system or new workflows.

• Lead and participate in compliance related audits or CMS related audits. Responsible for all metrics and reporting requirement pertaining to regulatory requirements.

• Responsible for UM department’s policies & procedures, workflows and job aids. This includes creation, maintenance and implementation of such documents.

• Participate in appropriate committees including but not limited to UM and QM committees.

• Serve as a change agent, assisting others in understanding the importance, necessity, impact and process of change through active involvement in decision making and coaching of leaders and staff.

• Utilize proven performance improvement methodologies and incorporates a strong emphasis on data to drive the implementation of improvements in the Organization’s UM operations and organizational culture in order to achieve improved outcomes metrics relative to the Triple Aim (improved population health, improved experience of care, and lower healthcare costs).

• Accountable for maintaining updated, current competencies, knowledge and skills in healthcare management trends, legal/regulatory and accreditation standards, and payer-based best practices in medical management and for the application of such current concepts within the Organization’s clinical operations strategies, processes and functions.

• Accountable for leadership and oversight of front line UM operational organization including care manager RNs, Medical Review RNs, and non-clinical customer service reps.

• Other duties as assigned or requested.

Minimum Education:

• Bachelor's Degree, Health/Clinical degree preferred (BSN, PA), or business related (Business, Health Administration) Preferred

• Master’s Degree in Business, Healthcare Policy, Health Administration, Economics, or related field or equivalency demonstrated through a combination of years of experience and proven skills

• Registered nurse. (RN)

Minimum Experience:

• 15+ years of experience in clinical services

• 5+ years of experience in health plan/payor management. Experience in medicare advantage health plan is preferred

• Subject matter expert in medicare related compliance/regulatory measures is strongly preferred.

• 10+ years of experience in a leadership position

• Significant experience in case management, utilization management, and population health with solid knowledge of best practices in all aspects of medical management

• Proven ability to use medical management metrics and to develop data-based initiatives designed to improve outcomes relative to the Triple Aim

• Demonstrated ability to lead and motivate clinical and administrative groups to achieve specific objectives Preferred

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

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