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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, and member risk data to identify strategic opportunities, evaluate program performance, and recommend actions that improve outcomes while responsibly managing total cost of care.

• Oversee Medicaid clinical policy governance and medical necessity criteria in partnership with clinical and operational stakeholders to ensure policies are evidence-based, clinically appropriate, operationally feasible, member-centered, and compliant with state and federal requirements.

• Partner with Clinical Operations, Care Management, Population Health, Behavioral Health, Pharmacy, and market leaders to modernize utilization and care management approaches, improve provider experience, support administrative simplification strategies such as gold carding, and ensure appropriate access to medically necessary care.

• Identify and prioritize major medical cost and utilization drivers, including high-cost utilization, specialty services, avoidable admissions, emergency department use, readmissions, post-acute care, transitions of care, site-of-care opportunities, gaps in care coordination, and unwarranted variation across markets.

• Advance strategic approaches that connect utilization insights to care management interventions, including improved referral pathways, transitions-of-care strategies, complex care management models, condition-specific interventions, and coordination for members with physical health, behavioral health, pharmacy, and social needs.

• Partner with Finance, Actuarial, Medical Economics, Analytics, and market leadership to establish executive scorecards, business cases, ROI frameworks, savings validation approaches, and performance management processes to track progress, quality impact, operational risks, and emerging opportunities.

• Partner with Medicaid clinical operations and market leadership to understand state-specific regulatory requirements, provider dynamics, local performance opportunities, care management requirements, population health priorities, and operational constraints. Support implementation of enterprise strategies with appropriate market flexibility and help scale leading practices across Medicaid markets.

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