Job Description
Job DescriptionThe Vice President of Medical Management provides executive leadership and strategic direction for all medical management functions, including utilization management, care management, population health, and quality improvement. This role ensures high-quality, cost-effective, and compliant care delivery across all lines of business, including Medicare Advantage. The VP partners closely with provider networks, operations, compliance, finance, and quality teams to align programs with organizational goals, regulatory requirements, and value-based care strategies.Key Responsibilities
- Develop and execute medical management strategies that support quality, affordability, and improved member outcomes.
- Serve as a key clinical and operational leader for enterprise-wide initiatives, including value-based care and population health.
- Provide executive-level reporting and recommendations to senior leadership and the Board.
- Oversee utilization management (prior authorization, concurrent review, retrospective review, appeals, and grievances).
- Lead care management programs, including case management, disease management, and transitions of care.
- Ensure evidence-based clinical decision-making and appropriate application of medical necessity criteria.
- Drive performance on CMS Star Ratings, risk adjustment, and compliance for MA products.
- Ensure adherence to CMS regulations, NCQA standards, and state requirements.
- Collaborate with risk adjustment teams to support accurate documentation and coding integrity.
- Promote best practices in clinical documentation, care coordination, and patient safety.
- Drive quality improvement initiatives and regulatory readiness for audits.
- Monitor performance on HEDIS, Stars, CAHPS, and other quality measures.
- Partner with provider networks to improve clinical outcomes, utilization efficiency, and provider engagement.
- Support value-based contracting strategies through clinical oversight and performance analytics.
- Act as a clinical liaison for complex cases and operational issues.
- Monitor utilization trends, cost drivers, and clinical outcomes to support medical cost management.
- Partner with Finance and Actuarial teams on forecasting, budgeting, and medical expense optimization.
- Use data analytics to drive performance improvement and operational efficiency.
- Lead, mentor, and develop medical management leadership and clinical teams.
- Foster a culture of accountability, collaboration, and continuous improvement.
- Ensure appropriate staffing models and clinical competencies across teams.
QualificationsEducation & Licensure
- Required:
- RN with BSN and a valid multistate license
- Master’s degree in Nursing, Public Health, or a related field
- Preferred:
- MD or DO
- Additional credentials such as Area of Critical Need (ACN) license or Foreign Medical Degree (FMD)
Experience
- 10+ years of progressive leadership experience in medical management, managed care, or healthcare administration.
- Direct experience with Medicare Advantage and CMS regulatory requirements.
- Demonstrated success in utilization management, care management, and quality programs.
- Experience in value-based care models preferred.
Skills & Competencies
- Strategic thinker with strong operational execution skills.
- Deep understanding of clinical quality, utilization, and cost management.
- Excellent leadership, communication, and stakeholder engagement abilities.
- Data-driven decision-maker with strong analytical skills.
Work EnvironmentCorporate office-based role with travel required to various center locations
Palm Medical Centers is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Medical Centers makes hiring decisions based solely on qualifications, merit, and business needs at the time.
Powered by JazzHR
lnagGDIWmE