Head of Utilization Management & Prior Authorization

VNS Health; New York (NY); On-site; USD 194,000 - 258,000; Full time

Job summary

VNS Health in New York is seeking a senior leader to oversee utilization management and medical management across plans, ensuring CMS and state regulatory compliance while driving process transformation and efficiency.

You will lead UM/CM programs, coordinate with medical directors, nurses, and provider networks, and develop policies, documentation standards, and performance metrics to improve quality and efficiency.

Qualifications

• Bachelor's degree in healthcare administration or related field required.
• Master's degree preferred.
• 8+ years of progressive UM/medical management experience.

Responsibilities

• Designs and implements utilization management programs and policies.
• Leads evaluation and redesign of UM and prior authorization processes.
• Oversees utilization review for medical necessity and efficiency.
• Provides leadership to UM team including nurses and case managers.
• Collaborates with cross-functional teams to ensure regulatory compliance.

Skills

Utilization management leadership

Prior authorization

Regulatory compliance

Process improvement

Cross-functional leadership

Education

Bachelor's degree in healthcare administration

Master's degree in healthcare administration/management

Job description

VNS Health in New York is seeking a senior leader to oversee utilization management and medical management across plans, ensuring CMS and state regulatory compliance while driving process transformation and efficiency.

You will lead UM/CM programs, coordinate with medical directors, nurses, and provider networks, and develop policies, documentation standards, and performance metrics to improve quality and efficiency.