AVP, Utilization and Care Management Strategy

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The AVP, Utilization and Care Management Strategy provides enterprise strategic leadership for Medicaid utilization management, care management, clinical policy governance, affordability initiatives, medical expense strategy, and performance oversight. Reporting to the VP, Medicaid Clinical Strategy and Affordability, this role leads the development and execution of a coordinated strategy designed to improve total cost of care, appropriate member access, care coordination, provider experience, quality outcomes, regulatory alignment, and program stewardship.

This is a strategy, governance, and cross-functional leadership role. The AVP is not expected to directly manage day-to-day utilization management or care management operations but will partner closely with operational leaders to shape priorities, establish strategic direction, define performance expectations, evaluate outcomes, and support scalable execution across Medicaid markets.

This leader is accountable for integrating utilization and care management strategy into a cohesive enterprise approach that supports the right care, at the right time, in the right setting, for Medicaid members. The role connects insights from authorization activity, utilization patterns, claims, denials and appeals, care management engagement, care gaps, admissions, emergency department use, post-acute utilization, high-risk member needs, and provider practice variation to inform enterprise strategy and market-level action.

The AVP serves as a strategic liaison to Medicaid market leadership and partners across Clinical Operations, Population Health Management, Behavioral Health, Pharmacy, Care Management, Network, Finance, Actuarial, Quality, Analytics, Payment Policy, Payment Integrity, and SIU. The role aligns enterprise utilization, care management, and affordability strategies with market realities, advances scalable solutions, and ensures disciplined governance across a significant clinical and financial performance domain.

This role is open to a physician leader and also to other highly qualified clinical or healthcare executives with deep experience in Medicaid managed care, utilization management, care management, clinical strategy, medical cost management, and complex matrixed leadership.

• Lead enterprise Medicaid utilization and care management strategy, including prior authorization strategy, Medicaid clinical policy governance, medical expense strategy, site-of-care optimization, provider practice variation, high-risk member strategy, and targeted affordability initiatives.

• Establish strategic direction, governance routines, performance expectations, and enterprise priorities for Medicaid utilization and care management, in partnership with operational leaders accountable for day-to-day execution.

• Oversee Medicaid care management strategy at the enterprise level to ensure programs are member-centered, data-driven, clinically effective, operationally scalable, and aligned with utilization, quality, access, regulatory, and affordability goals.

• Integrate utilization management and care management strategies to identify members with rising risk, complex needs, avoidable utilization, care gaps, and opportunities for earlier intervention, improved care coordination, and more appropriate site-of-care decisions.

• Use utilization, authorization, denial, appeal, claims, care management, quality, medical expense,