Prior Authorization Utilization Review Jobs in Rochester, NY

The Vice President of Quality Improvement and Utilization Management serves as the senior clinical quality and utilization leader for Nascentia Health's Payer/Plan Engine, providing executive oversight across all lines of business including the Managed Long-Term Care (MLTC) plan (approximately 7,000 members), the Medicare Advantage Prescription Drug Plan (MAP), the Institutional Special Needs Plan (ISNP), the Dual Eligible Special Needs Plan (DSNP), and related product lines. This role is responsible for designing, leading, and continuously improving all quality improvement, HEDIS/Stars performance, utilization management, and regulatory compliance programs in a manner that advances member outcomes, meets or exceeds CMS and NYS Department of Health standards, and positions Nascentia Health as a high-performing plan in the communities it serves. The VP reports directly to the President of Health Plans and serves as a key leader within the enterprise Payer Engine.

Performance Responsibilities and Standards:

Quality Improvement & Medicare Stars

• Lead the design, implementation, and annual refresh of the organization-wide Quality Improvement Program (QIP) for all plan lines, including MLTC, MAP, ISNP, and DSNP.
• Own CMS Star Ratings strategy for the Medicare Advantage and SNP portfolios; develop and execute targeted interventions to achieve and sustain 4-Star or better ratings across applicable measures.
• Oversee the Director of Health Plan Quality & Utilization Review Management and supporting staff in directing all HEDIS, CAHPS, HOS, and NYS QARR data collection, production, and submission processes, ensuring accuracy, timeliness, and regulatory compliance.
• Partner with clinical, care management, and provider relations teams to implement evidence-based quality improvement initiatives that reduce gaps in care across the membership.
• Develop and monitor quality dashboards and scorecards, reporting performance trends to the President of Health Plans and enterprise leadership on a monthly and quarterly basis.
• Lead NCQA accreditation preparation and maintenance activities across applicable product lines.
• Serve as the plan's primary point of accountability for CMS, NYS DOH, and NCQA quality-related audits, desk reviews, and performance improvement plan responses.
• Direct the annual evaluation of the Quality Improvement Program (QIP) across all health plan products, including MLTC, MAP, ISNP, and DSNP.

Utilization Management

• Provide oversight of all UM functions for MLTC and Medicare product lines, including prior authorization, concurrent review, level of care determination, and appeals/grievances.
• Ensure UM programs comply with all applicable federal and state requirements including InterQual/Milliman criteria application, MLTC Model Contract standards, and CMS Medicare Managed Care Manual requirements.
• Direct the development and annual review of UM policies, procedures, and clinical criteria consistent with regulatory requirements and evidence-based standards.
• Oversee the Director of Health Plan Quality & Utilization Review Management and supporting clinical staff, ensuring appropriate staffing, training, and performance management across the UM function.
• Monitor UM performance metrics including authorization turnaround times, denial rates, appeal outcomes, and overturn rates; identify trends and implement corrective action as needed.
• Collaborate with the Medical Director and care management leadership to ensure clinically appropriate decision-making and continuity of care for complex members.
• Manage TPA and UM vendor relationships as applicable, ensuring service level agreements are met and plan standards are upheld.
• Direct the annual evaluation of the Utilization Management Program in accordance with CMS, NCQA, and New York State regulatory requirements.

MLTC-Specific Quality & Compliance Oversight

• Lead quality oversight for Nascentia's MLTC plan, including UAS assessment quality, care plan compliance, member rights and grievances, and provider network performance monitoring.
• Ensure ongoing compliance with NYS MLTC Model Contract quality requirements, including development and submission of required quality reports, corrective action plans, and performance improvement projects (PIPs).
• Direct population health and quality improvement strategies tailored to the MLTC membership, with a focus on aging-in-place outcomes, functional status, and avoidable hospitalization reduction.
• Collaborate with care management, enrollment, and member services leadership to ensure integrated quality performance across the member experience continuum.

Medicare SNP Quality (ISNP/DSNP)

• Lead Stars and quality performance strategy for the ISNP and DSNP product lines, including H-code specific CMS reporting and model of care (MOC) development, implementation, and oversight.
• Direct annual Model of Care submissions and related evaluations for SNP compliance, partnering with the Medical Director and care management teams on evidence-based clinical protocols.
• Develop strategies to scale quality performance as the SNP membership grows, ensuring infrastructure, staffing, and tools are positioned to support plan expansion.

Regulatory, Compliance & Reporting

• Serve as the plan's designated quality officer for regulatory interactions with CMS, NYS DOH, and NCQA; prepare and present quality performance reports to the Board, leadership team, and regulatory agencies as required.
• Lead preparation for and response to CMS program audits (ISNP/DSNP Audit Protocol, Medicare Advantage), NYS DOH MLTC oversight reviews, and NCQA accreditation surveys.
• Ensure the quality improvement activities are properly documented and reported in compliance with CMS and state requirements.
• Maintain current knowledge of evolving CMS Star Ratings methodology, HEDIS measure updates, and NYS MLTC regulatory changes; proactively brief leadership on implications for plan strategy.

Leadership, Team Development & Cross-Functional Collaboration

• Recruit, develop, and retain a high-performing quality and UM team; foster a culture of accountability, continuous learning, and data-driven decision-making.
• Partner with the Chief Clinical Officer, Medical Director, and clinical operations leadership to align quality improvement initiatives across the Payer and Provider engines of the enterprise.
• Collaborate with the data analytics and IT teams to build and maintain quality data infrastructure, dashboards, and reporting tools that support real-time performance visibility.
• Serve as the internal subject matter expert on health plan quality regulations, Stars methodology, and UM best practices; educate and advise organizational leaders as the enterprise scales.
• Participate in enterprise-level operating reviews including monthly reviews, quarterly strategic reviews, and annual planning cycles.
• Performs all other duties as assigned.

Experience / Qualifications:

• Bachelor's degree required in nursing, public health, administration, or a related field; Master's degree preferred or applicable extensive experience.
• Minimum of 10 years of progressive healthcare quality and/or utilization management experience, with at least 5 years in a director or VP-level leadership role within a health plan environment.
• Demonstrated expertise in Medicare Stars Ratings programs, HEDIS, CAHPS, and NYS QARR; track record of driving measurable Stars improvement preferred.
• Direct experience with MLTC, Medicaid managed care, and/or Medicare Special Needs Plans (ISNP, DSNP) strongly preferred; familiarity with NYS MLTC Model Contract requirements is a significant asset.
• Knowledge of utilization management operations including InterQual or Milliman criteria, prior authorization workflows, appeals/grievances processes, and UM regulatory standards.
• Experience with NCQA accreditation preparation, CMS program audits, and NYS DOH oversight processes.
• Strong analytical skills with the ability to interpret complex quality data, identify trends, and translate findings into actionable improvement strategies.
• Demonstrated ability to build, lead, and develop clinical and administrative teams in a mission-driven managed care environment.
• Experience working within or alongside a multi-entity, multi-product health plan organization; comfort operating in a maturing governance and enterprise design environment.
• Proficiency in Microsoft Office, quality reporting platforms, and health plan data/analytics tools; experience with clinical data warehouses and UM authorization systems a plus.
• Excellent written and verbal communication skills; ability to present complex information clearly to executive leadership, board members, and regulatory agencies.
• Commitment to the mission of Nascentia and helping people Age in Place; alignment with Nascentia Health's values of community-rooted, whole-person care.

Work Environment & Physical Requirements:

• Speaking/visual/hearing ability sufficient to comprehend and express written and verbal communication.
• Frequent sitting, standing, and computer use in an office or hybrid environment.
• Extended periods of computer use for data analysis, report preparation, and virtual meetings.
• Ability to travel locally and regionally for regulatory meetings, provider engagements, and organizational events as needed.

Compensation & Benefits

Competitive Salary [This position is an S11 exempt position with a min-max rate of: $157,427 - $203,581/annually]with:

• Retention Bonuses
• Internal Mentoring Program
• 401K with generous Employer match
• On-Site Gym (free for all employees)
• Potential Hybrid Position (Partial Work From Home)
• Medical, Dental, Vision plans
• Tuition Reimbursement
• Partially funded HSA
• Employee Recognition Platform
• Paid Time Off, Holidays, Sick and Extended Sick Leave
• Short/Long term Disability
• Employee Assistance Program (EAP)
• Much More!

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About Nascentia Health:

Nascentia Health is leading the way in home care, post acute care and long-term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.

Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community-based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team.

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Nascentia Health is an Equal Opportunity Employer (EOE)

Employment is contingent upon negative results of a pre-hire drug screen and background check clearance