AVP, Utilization Management in United States at Jobgether
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Job Description
This position is posted by Jobgether on behalf of a partner company. We are currently looking for an AVP, Utilization Management in the United States.
This senior leadership role is responsible for driving enterprise utilization management strategy and ensuring operational excellence across key clinical and revenue cycle processes. You will oversee programs focused on prior authorization, medical necessity review, and concurrent review while ensuring compliance with regulatory, payer, and CMS requirements. Operating at the intersection of clinical operations, finance, and revenue cycle performance, you will play a critical role in reducing preventable denials and improving reimbursement outcomes. The position requires strong executive leadership, strategic thinking, and the ability to influence large, cross-functional teams in a complex healthcare environment. You will also lead and develop operational leaders, shaping long-term organizational capability and performance. This is a high-impact role with visibility across enterprise stakeholders and responsibility for driving measurable improvements in care coordination and financial outcomes.
In this role, you will lead the execution of utilization management strategy and oversee operational performance across assigned programs, ensuring alignment with regulatory, clinical, and financial objectives.
- Lead execution of enterprise utilization management strategies aligned with regulatory and organizational goals
- Oversee prior authorization, medical necessity, and concurrent review operations across service lines
- Ensure compliance with CMS, payer, and state regulatory requirements while mitigating audit and reimbursement risks
- Monitor performance metrics such as denial trends, utilization efficiency, and operational effectiveness
- Drive data-informed performance improvement initiatives to optimize clinical and financial outcomes
- Collaborate with clinical, case management, and revenue cycle teams to improve documentation and reduce denials
- Lead, mentor, and develop managers and senior operational leaders across utilization management functions
- Support technology adoption and workflow optimization to enhance utilization management processes
- Contribute to succession planning and enterprise capability development
The ideal candidate brings extensive experience in utilization management, healthcare operations, and team leadership within complex healthcare environments. You demonstrate strong strategic, analytical, and leadership capabilities with a focus on operational transformation and compliance.
- Bachelor’s degree or equivalent combination of education and experience required
- Active RN license required
- 10+ years of experience in utilization management, healthcare reimbursement, or related clinical operations roles
- 5+ years of leadership experience managing teams or operational functions
- Strong understanding of CMS, payer requirements, and healthcare regulatory frameworks
- Demonstrated ability to lead cross-functional initiatives and influence senior stakeholders
- Strong analytical and problem-solving skills with a data-driven approach to decision-making
- Excellent communication and executive presence, with the ability to influence and lead change
- Experience leveraging technology and AI-enabled tools to improve operational outcomes is strongly preferred
- Willingness to travel up to 25%, including occasional onsite or client visits
- Competitive base salary ranging from $134,000 to $167,500 depending on experience
- Performance-based bonus incentives
- Comprehensive medical, dental, and vision insurance
- Retirement savings plan (401k)
- Paid time off, holidays, and wellness programs
- Tuition reimbursement and professional development opportunities
- Certification and career advancement support
- Remote-first work model with travel flexibility as needed
- Inclusive, growth-oriented, and innovation-driven work environment