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CVS Health VP, Utilization Management in Hartford, Connecticut

Req ID: 72424BR

Job Description

Vice President, Utilization Management

The Vice President of Utilization Management (UM) Operations is responsible for providing leadership and direction for over 2500 clinical staff spanning multiple regional locations to ensure consistent, efficient and impactful delivery of clinical programs for Aetna’s Commercial and Medicare populations. The Vice President will lead day to day operational functions to ensure timely and accurate clinically based execution of initiatives for markets serving approximately 18.7 million members, supported by an operating budget of approximately $320 million.

This role is a strategic leadership position requiring innovation and collaboration to influence Aetna’s continued focus on creating additional value for the member. Working closely with the enterprise Chief Medical Officer, Commercial, Medicare segment business leaders and clinical leaders, this position will develop and deploy innovative clinical programs, services and methods of care that create more healthy days for our members. This leader will have the opportunity to lead the shift from traditional utilization management to a more consumer-centric, collaborative approach focused on population health by employing the use of innovation including AI, robotics and predictive analytics to drive transformative change.

Reporting Relationships

The Vice President of UM Operations will report to the SVP of Clinical Services. This role will provide leadership and direction to the UM operation and direct leadership over the following functions: Intake, Precertification/Predetermination, Concurrent Review and Discharge Planning, Clinical Claim Review/Clinical Claim Editing, UM process optimization.

Fundamental Components included but are not limited to:

Principal Accountabilities

  • Oversight and accountability for the UM clinical services organization by setting strategic goals and objectives for the UM organization.

  • As a key member of the Clinical Services management team, participate in the development of short-term and long-term strategic plans required for Aetna’s ongoing growth and success. Collaborate with the team to reach a shared vision regarding clinical service operations and align the development of the function and respective resources with business growth objectives.

  • Provide thought leadership in the formation of the UM transformation strategy that moves Aetna's traditional utilization management from a transactional approach to value incorporating decision support, automation, risk management and provider experience.

  • Develop and foster strong working relationships and communication at all levels of the organization. Foster an environment of collaboration and communication between key functional areas to ensure timely implementation of new strategies and coordinate implementation of corrective strategies to resolve problems or situations that may arise. Problem-solve issues that are barriers to expected operational results.

  • Serve as a focal point between corporate medical economics, market president, medical directors, network and clinical operations through leadership and collaborative style. Hold each region's management team accountable for their individual region's performance while serving as an advocate for their needs in the corporate office.

  • Develop and regularly communicate key operational metrics that systematically measure performance versus plan against medical costs and trends. Develop a communication channel that acknowledges performance improvement in the organization and the respective impact on employees, members, providers, and other stakeholders.

  • Ensure the highest standards (top quartile) of efficiency and stakeholder experience for clinical service operations and processes. Regularly assess current state of clinical operations against industry standards for productivity, quality, and cost. Identify service gaps and opportunities for performance improvement.

  • Proactively builds and maintains solid relationships with the Payer and Provider community by influencing decision making and ensuring quality and satisfaction standards are met.

  • Works closely with Aetna clinical teams to assist in designing policies that support the facilitation of care and minimizes administrative burdens for providers, members and Aetna.

  • Develop a comprehensive plan designed to address operational improvement opportunities, including a strategy for market-leading performance. Develop short-and long-term goals/objectives with respective timelines and budgetary recommendations.

  • Uses data and analytics to inform decisions about what current strategies are producing value for the member, provider, and Aetna.

Qualifications Requirements and Preferences:

Experience and Qualifications

  • The successful candidate will possess a bachelor’s degree; master’s degree in business or health administration is highly preferred.

  • 15+ years progressive, related business management experience in a high-impact role with track record of success leading regional or national operations of managed care and/or healthcare services.

  • Prior experience overseeing a medical management/clinical services organization desired, with a track record of creating new strategies that support new consumer care management

  • Demonstrated leadership capacity to assume oversight and accountability for the operations of a growing business and the ability to lead and motivate people to achieve agreed-upon results.

  • Extensive capacity to think strategically, effective communication skills and a proven track record of building and maintaining multiple successful partnerships.

  • Proven ability to effect change and meet business goals, monitor progress, and take corrective actions when necessary.

  • Experience working proactively with all stakeholders to identify and meet their needs and requirements.

  • Comprehensive knowledge of managed care operations and how they can work to improve quality of care and reduce costs, including core operations, network management, provider relations and medical management/care management. A deep understanding of clinical service operations.

  • Proven ability to understand business strategies and formulate concise solutions to complex problems. Prior experience of leveraging analytics in business decision.

  • Strong manager of organizational talent who actively seeks to build, manage, and continuously improve the organizational talent of the company.

  • Exceptional written and verbal communication skills. Experience in effectively simplifying and presenting complex information.

  • Strong analytical and critical thinking skills. Focus on driving disciplined, fact-based decisions, and executing with discipline and urgency.

  • Success in simplifying and rationalizing UM, clinical assets and technology offerings based on market value and true return on investment.

  • Experience in rationalizing a current portfolio and decision making on stop/start/continue initiatives to deliver value.

  • Success in moving from current traditional strategies to new, modified approaches.

Benefit Eligibility

Benefit eligibility may vary by position.

Job Function: Management

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