Vice President, Utilization and Benefit Managment

Role and Responsibility:
•Lead the ongoing development and operational design for utilization management, clinical / reimbursement policy, and member benefits
•Ensure alignment of functional areas in order to best serve our members and providers
•Ensure alignment to evidence based and best practice across functional areas of responsibilities and associated strategies are deployed across Enterprise, Markets, and Products
•Provide strategic direction design across functional responsibilities in accordance with requirements; regulatory, URAC, HEDIS, NCQA and future business related standards
•Ensure functional areas are properly developed and aligned to the organization’s strategic goals
•Ensure the incorporation of our Population Health approach into utilization management design, working with market leaders to ensure alignment
•Ensure the development and maintenance of documentation and process change control related to workflow, ensuring compliance with requirements and accomplishment of business objectives and goals
•Identify long-range, competitive strategies for utilization management, policy, and member benefits
•Oversee benefit management, ensuring benefits are effectively captured and drive the desired outcomes of Population Health
•Maintain high-level knowledge of clinical practice; coordinating and standardizing operations for all products and markets in the CareSource portfolio
•Partner with medical directors, enterprise, and market leaders in the development of best practices and shared learning
•Assist CareSource leaders with necessary adaptations to UM practices and policies to comply with market/product contractual requirements that best serve the holistic needs of members
•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
•Cultivate and promote the CareSource culture to improve the health outcomes of our members
•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
•Perform any other job related instructions as requested

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