Company :

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 for Utilization Management, defining granular critical success metrics to gauge transformational impact, validate market leadership, and quantify the realization of monumental strategic initiatives that redefine core business functions.
• This role provides executive leadership for direct reports and the broader UM organization, contributing to hiring, talent development, succession planning, and performance management; with the aim to cultivate a strong leadership team capable of executing long-term strategies with significant business impact.
• Other duties as assigned.

EXPERIENCE

Required

• 15+ years in the Health Insurance Industry, demonstrating a profound understanding of payer operations and the broader healthcare ecosystem, ideally at a large, complex organization.
• 10+ years in Strategic Operational Planning, inclusive of spearheading successful, large-scale, enterprise-wide organizational transformations that have significantly altered market position or financial outcomes.
• 10+ years in a senior Operational Leadership role within a large-scale, intricate organization, evidencing mastery in leveraging levers for monumental efficiency and exponential scale.
• 10+ years of direct healthcare cost containment experience in Payment Integrity, Claims, or Utilization Management experience
• Proven, hands-on experience in business development, market expansion, or managing significant P&L responsibilities for complex service offerings.
• Demonstrable track record of leading and orchestrating enterprise-wide change initiatives and driving transformative process improvement methodologies at the highest executive level.

Preferred

• 5+ years in a dedicated technology leadership role, or substantial executive experience overseeing technology-driven transformation as a primary strategic mandate for a large organization.
• 5+ years in quality improvement initiatives at large scale organizations inclusive of end to end reform of operating model redesign to maximize speed, quality, and cost of operations
• 3-5 years of Medicaid Experience preferred

EDUCATION

Required

• Bachelor's degree in Nursing, Health Plan Administration or Business Administration/Management

Substitutions

• May substitute another 4-year degree or 10+ years of substantive experience in a VP of Operations or Chief Operating Officer role in the Health Insurance Industry in combination with the other experience and skills required above.

Preferred

• None

LICENSES OR CERTIFICATIONS

Required

• None

Preferred

• 2-5 years in technology
• Experience managing Medicaid and clinical teams.
• PMP or Lean Six Sigma Master Black Belt certification is highly preferred, evidencing a commitment to structured strategic execution and transformational quality leadership.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. 
 
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. 
 
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.  
 
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.  

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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