AVP, Utilization Management

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.

Accountabilities

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

Requirements

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

Benefits

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

How Jobgether works:

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

Why Apply Through Jobgether?

Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.

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Requirements

Benefits

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