Executive Director, Utilization Management Center of Excellence

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Position Summary

At Aetna, our health benefits business, we are committed to helping our members achieve their best health in an affordable, convenient, and comprehensive manner. Combining the assets of our health insurance products and services with CVS Health’s unrivaled presence in local communities and their pharmacy benefits management capabilities, we’re joining members on their path to better health and transforming the health care landscape in new and exciting ways every day.

Aetna is recruiting an Executive Director, Utilization Management (UM) Center of Excellence (COE) who will lead the development and execution of strategic initiatives that support UM operations, ensuring compliance with all regulations, optimizing performance, and delivering exceptional outcomes. This leader will oversee the precertification process, grievances and appeals management, turnaround time (TAT) adherence, and ensure the organization meets NCQA accreditation standards and state Medicaid requirements. This position is ideal for a visionary leader with broad-based expertise in UM, regulatory compliance, performance optimization, and operational excellence across diverse lines of business.

You'll make an impact by:

Leadership and Strategic Oversight

• Developing and leading a high-performing Center of Excellence (COE) team to support UM operations, ensuring best-in-class performance and member outcomes.

• Driving strategic initiatives to enhance UM processes, minimizing grievances and appeals, and ensuring compliance with all state, federal, and NCQA standards.

• Fostering a culture of collaboration, continuous improvement, and accountability.

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Regulatory Compliance and Governance

• Maintaining expert knowledge of state Medicaid rules, NCQA accreditation requirements, and federal regulations to ensure operational compliance.

• Acting as the primary liaison with regulatory bodies during audits and assessments, ensuring audit preparedness and success.

• Establishing a robust framework for interpreting and operationalizing regulatory changes.

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Operational Excellence

• Optimizing workflows, technology, and resources for efficient and accurate precertification, authorization processes, and appeals management.

• Leading initiatives to reduce grievances and appeals through root cause analysis, provider/member education, and policy adjustments.

• Overseeing learning and performance programs to ensure staff are well-equipped to meet operational goals.

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Performance Management and Analytics

• Establishing and monitoring key performance indicators (KPIs) for UM operations, including TATs, grievance/appeals rates, and member satisfaction metrics.

• Leveraging advanced analytics and dashboards to drive data-informed decision-making and continuous improvement.

• Providing regular reports and insights to senior leadership on UM outcomes, trends, and improvement opportunities.

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Innovation and Best Practices

• Driving adoption of innovative technologies, such as AI and machine learning, to streamline UM processes and enhance efficiency.

• Benchmarking against industry standards to identify and implement best practices.

• Fostering an organizational culture that values creativity, forward-thinking, and proactive problem-solving.

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Stakeholder Collaboration

• Partnering with clinical teams to align UM strategies with broader care management and population health goals.

• Engaging providers to support network alignment with UM requirements,