AVP, Utilization Review & Pharmacy

Zurich Insurance is seeking an AVP, Utilization Review & Pharmacy. This is a fully remote position, offering the flexibility of a home-based office.

As the AVP of Utilization Review & Pharmacy, you will lead and direct a team of Utilization Review and Pharmacy nurses who are responsible for the review of clinical services for the determination of medical necessity and appropriateness of care of our insureds’ injured employees. You will develop, recommend and execute short- and long-term strategies that enable utilization review and pharmacy to achieve profitability goals and ensure the delivery of quality, cost effective services to our Managed Care stakeholders. You will act as a subject matter expert and technical resource to Managed Care stakeholders regarding operational and regulatory cost containment issues. This position has clear and distinct accountability for business results and works with Managed Care and Claims leadership to create and align utilization and pharmacy cost containment strategies with our customers’ need. This role also involves managing and overseeing team activities, and being responsible for the performance, development, and coaching of staff to maximize contributions and drive employee growth and improvement.

Key Responsibilities:

• Provide oversight and accountability for the utilization review and pharmacy operations by ensuring the delivery of high quality and cost effective services
• Participate in the development and implementation of a strategic plan for the utilization review and pharmacy functions by evaluating and improving the efficiency of business processes and best practices to enhance customer service, technical excellence quality and employee engagement.
• Drive technical excellence by determining and managing key performance metrics associated with utilization review and pharmacy
• Respond to escalated customer and regulatory inquiries accurately and in a professional manner by researching issues, determining root causes and implementing solutions.
• Develop and implement process improvement ideas to improve efficiency of functional area.
• Provide oversight and accountability for UR and pharmacy operation’s culture of continuous improvement of the clinical expertise across the organization.
• Motivate and lead a high performance team by attracting, onboarding, recruiting and retaining team members.
• Drive the performance management process by communicating job expectations, monitoring and evaluating performance, providing feedback and facilitating employee development.

Basic Qualifications:

• Bachelors Degree and 7 or more years of experience in the Nursing area
  AND
• Registered Professional Nurse license in residential area and in operational national/local areas as mandated by jurisdictions
• 5 or more years of clinical experience in medical/surgical, orthopedic neurosurgical, psychiatric nursing, or rehab field
• Experience in development and implementation of cost containment programs
• Case management, utilization review, catastrophic or disability experience
• 5 or more years of management experience
• Experience in outcome measurements to determine effectiveness of the programs
• Experience in servicing customers
• CDMS
• CCM
• CRRN
• COHN
• CRS
   

Preferred Qualifications:

• People and performance management experience
• Experience in outcome measurements to determine the effectiveness of programs
• Thorough understanding of the workers’ compensation claims process, including regulatory compliance, documentation, and coordination with stakeholders
• Strong leadership experience
• Strong verbal and written communication experience
• Strong organization skills
• Analytical and problem-solving skills
• In-depth knowledge of the insurance industry