Vice President, Preservice Utilization Management (Optum West ) – Remote

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The Vice President of Preservice Review Optum West is responsible for establishing the strategic direction and successfully executing all Preservice Review activities for Optum West markets. This role is responsible for planning, organizing, and directing the administration of all regulatory, delegated, and strategic programs for outpatient & inpatient preservice activities. The VP provides oversight to ensure activities are appropriately integrated into strategic direction and operations, as well as the mission and values of the company. The position will be accountable for continuous process optimization and will provide support and leadership in the integration of all Optum West markets. This role is an important part of the Optum West leadership team and works directly with local, regional and national leaders, including but not limited to operations, physician leadership, contracting, finance, medical directors, pharmacy, delegation, claims to ensure compliant and high-performing processes and outcomes. This position interfaces regularly with Optum’s Market and Provider Relation’s leadership teams to ensure excellent member and provider experience of care across Optum.  

The VP is responsible for supporting organizational structure in alignment with the One Optum West vision, focused on achieving our strategic goals, implementing best practice programs and standardizing processes where appropriate to drive efficiency and consistency in employee, provider and member experiences. The VP maintains organizational structure and oversight of procedures, employment, training, and supervision of all preservice review staff. The role coordinates duties with appropriate personnel to meet operational program needs and ensures compliance with state and federal health plan requirements as well as ensuring Optum members receive appropriate access to care and coordinated, evidence-based services. The role is also responsible for cultivating new leadership for the department and fostering a positive cultural environment to enhance employee experience.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities: 

• Owns accountability for the following topics for Optum West (currently 2M+ patient lives and growing), including:
  • Driving the identification and execution of strategies to deliver total cost of care savings through appropriate use of medical necessity and prior authorization guidelines
  • Actively consuming medical expense and pharmacy analytics to support strategic execution of best practice affordability programs
  • Contributing to ongoing improvement of prior auth & UM analytics, including leakage review/action planning and network management processes
• Leads the integration of medical management teams and serves as a thought leader in the expansion of preservice review programs to support quality, affordability initiatives, network optimization, and compliance to better serve Optum members
• Applies an enterprise mindset to strategy and vision development, establishing challenging and achievable goals, leading the team to deliver on outcomes
• Innovative thinking to support and drive operational and strategic changes aligned with the organizational mission and vision
• Development, implementation and oversight of people, processes and technology required to achieve strategic plans
• Actively collaborates with internal stakeholders and external partners, payers, and regulatory agencies to transform the health care experience for Optum customers and members
• Develop and lead efforts to achieve financial performance consistent with division and market goals
• Support regional clinical leaders in developing and managing annual scorecards of $100M+ in prioritized medical management and network strategy initiatives across core themes including:
  • Reducing inappropriate facility utilization
  • Effective use of wraparound services (e.g. disease management programs)
  • Optimal Care (evidence-based medicine)
  • Strategic network management (contracting and network structure opportunities)
  • Pharmacy Part B strategies
  • Payment integrity
• Oversees and ensures compliance and adherence to all state and federal regulations, contractual agreements, and other applicable accreditation standards. In addition, ensures adherence to other UM/CM/DM delegated agreement standards and expectations for all contracted health plans
• Create the culture, systems, and processes that support consistent audit-readiness. Ensures internal audits are conducted, reviews results, formulates and implements appropriate action plans to correct any areas of noncompliance. Develop and oversee implementation of Corrective Action Plans as needed 
• Encourages staff to develop skills and knowledge for personal growth and promotion of position. Fosters leadership skills for supervisor positions to ensure qualified staff performs management of processes. Promotes appropriateness in the utilization of staff by being flexible and assisting others when a staffing problem occurs. Identifies and helps develop future leaders
• Actively participate as a key member of the medical management sr. leadership team and develops action plans to improve Employee Engagement, Diversity & Inclusion and Drive our Health Equity Goals

The information listed above is not comprehensive of all duties/responsibilities performed. This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

Required Qualifications:

• 10+ years of experience in managed care and/or utilization management (preservice, inpatient, medical claims review, etc.)
• 7+ years of management level experience

Preferred Qualifications: 

• Registered nurse with unrestricted, active license in state of residence 
• Familiar with CA state laws regarding health plan regulations

Professional Competencies:

• Solid clinical leadership skills to ensure trust and respect of clinical staff
• Solid operational mindset and ability to use data to draw insights
• Solid ability to communicate in written and verbal presentations
• Solid relationship development and team management skills 
• Results oriented, capable of clearly translating strategic objectives into implementation plans that drive outcomes
• Success in driving organizational change and performance improvement 
• Solid collaboration skills to ensure effective alignment among diverse teams
• Ability to excel in a matrixed environment 

Work Environment:

• The majority of work responsibilities are performed remotely or in an office setting, carrying out detailed work sitting at a desk/table and working on the computer. Travel will be required

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $147,300 to $282,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.  

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.    

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.   

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.