VP, Enterprise Utilization Management Strategy & Excellence

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This role is responsible for developing, implementing and executing the comprehensive strategic vision and profound transformation of Highmark’s Enterprise Utilization Management function, ensuring impactful market positioning and cost containment, across all lines of business (e.g., Medicare, Medicaid, commercial, ACA). The incumbent will establish Highmark as an industry leader through strategic and operational transformation that aligns with the organization’s member focused strategy. They are accountable for an operational organization with over 1,000 service level requirements, ensuring compliance and mitigating risks associated with non-compliance with a broad range of government mandates and regulations. They champion continuous improvement and implement industry-best practices to achieve these critical performance and compliance objectives. This role is also responsible for delivering UM operations for external health plans and administrators.

This incumbent would also provide executive oversight for operational and processing problems and consequences (e.g., financial, reputation, customer service) related to Medicaid, Medicare, commercial, ACA and others, ensuring adherence to corporate, State, and Federal performance measures and compliance to mandates for enrollment, benefit processing, billing, claims processing, and customer/provider service. Partner closely with all Business Leaders to ensure the successful implementation of critical strategic initiatives and account/customer satisfaction through effective operational administration for each line of business.

This position is accountable for quality UM outcomes, including operational delivery and transformation, while managing a broad workforce and operational footprint, inclusive or talent and performance management. The incumbent champions the adoption of advanced technology and pioneering strategic frameworks to fundamentally reshape how UM is delivered, both within Highmark’s existing structure and as a leading-edge service offering to external entities.

ESSENTIAL RESPONSIBILITIES

• Architect and rigorously execute the multi-year strategic roadmap for Utilization Management across Highmark’s 5M members, ensuring uncompromising alignment with Highmark’s Living Health strategy. Precisely position Highmark as a recognized leader in UM through ground-breaking practices and the highest quality for our members
• Drive ambitious quality programs targeting exceptional decision accuracy, establishing a new standard of performance that surpasses current industry outcomes. Forge strategic partnerships and harness technological advancements to attain unparalleled reliability in UM processes and outcomes.
• Identify, cultivate, and seize opportunities to significantly grow and expand revenue through sophisticated Utilization Management Business Process as a Service (BPaaS) offering, thereby developing a robust, non-Highmark profit and loss capability for end-to-end UM management. This encompasses strategically engaging with and offering UM capabilities to external organizations, extending Highmark's reach.
• Lead critical cross-enterprise commitments, guaranteeing the delivery of exceptionally high-value, effective, and rigorously governed UM. Collaborate with all Highmark divisions to meticulously integrate and align UM strategies, technologies, and outcomes, impacting enterprise-wide financial performance and operational synergy at a significant scale.
• Define and champion the strategic direction for UM technology and automation, including spearheading the prioritization and funding of the platform and technology change enhancement backlog, and guiding transformative initiatives such as advanced automation for authorization data intake and streamlined auto-approval processes. Drive digital authorization management solutions to dramatically curtail reliance on archaic manual methods, setting the pace for digital adoption.
• Oversee Utilization Management across all business lines and states, ensuring processes and controls are in place to meet contractual SLAs and regulatory requirements for CMS, state Medicaid agencies and others.
• Establish the overarching strategic blueprint for a globally optimized UM workforce. This involves setting the strategic direction for optimizing complex offshore vs. onshore staffing models, overseeing sophisticated demand forecasting methodologies, and ensuring long-term staff allocation strategies meticulously align with profound transformational goals. Develop and foster a holistic framework for enterprise-level employee engagement initiatives across the vastly evolving organization, affecting hundreds to thousands of employees.
• Design, implement, and rigorously oversee the strategic performance framework f