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Vinfen

VP of Nursing

Cambridge, MA

The Vice President (VP) of Nursing works in conjunction with the Chief Medical Officer (CMO) to support a culture of health promotion, disease intervention, and professional supervision of the ...

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VP of Utilization Review

ODYSSEY BEHAVIORAL GROUP

Franklin, TN • On-site, Remote

Full-time

Posted 10 days ago

Job description

Position Summary
The Vice President of Utilization Review (VP of UR) provides strategic and operational leadership for the enterprise-wide Utilization Review function across all behavioral health service lines and levels of care. This executive leader is responsible for developing, standardizing, optimizing, and overseeing utilization management practices that support quality care, appropriate reimbursement, regulatory compliance, payer relationships, and organizational financial performance.
The VP of UR partners closely with Executive Leadership, Clinical Operations, Revenue Cycle, Admissions, Nursing, Compliance, Business Development, and Finance to ensure utilization management processes align with organizational goals, evidence-based practices, and payer requirements. This role is responsible for driving performance improvement initiatives related to authorizations, denials management, length of stay optimization, appeals, documentation integrity, and payer strategy.
The VP of UR serves as the enterprise subject matter expert for utilization management and develops scalable systems, reporting structures, KPIs, and accountability processes to support continued organizational growth and operational excellence.
Relationships and Contacts
Within the organization: Maintains frequent and collaborative working relationships with the Chief Clinical Officer, Executive Leadership, Divisional CEOs, Chief Financial Officer, Revenue Cycle leadership, Business Development, Admissions, Nursing leadership, Medical leadership, Compliance, Risk Management, Operations leadership, and all clinical team members across the organization.
Outside the organization: Develops and maintains strategic relationships with insurance organizations, managed care companies, external review organizations, payer representatives, referral partners, vendors, and consultants, as appropriate.
Position Responsibilities
Essential Responsibilities
  1. Provides executive oversight and strategic direction for all enterprise Utilization Review operations across multiple facilities, service lines, and states.
  2. Develops and implements standardized enterprise-wide UR processes, workflows, policies, and documentation standards to improve operational consistency and payer outcomes.
  3. Oversees authorization management, concurrent review processes, denial prevention strategies, appeals management, retrospective reviews, and payer escalation processes.
  4. Partners with Clinical, Nursing, Admissions, and Revenue Cycle teams to ensure documentation supports medical necessity, level of care determinations, and reimbursement optimization.
  5. Develops enterprise KPI dashboards and reporting structures related to denials, overturn rates, authorization timeliness, payer trends, reimbursement performance, length of stay management, and utilization efficiency.
  6. Identifies trends, gaps, and opportunities within utilization management processes and leads performance improvement initiatives to enhance operational and financial outcomes.
  7. Collaborates with executive leadership regarding payer contracting strategy, authorization challenges, network access issues, and value-based care initiatives.
  8. Serves as an organizational expert regarding payer requirements, medical necessity criteria, utilization management regulations, and behavioral health reimbursement practices.
  9. Oversees recruitment, onboarding, training, mentorship, performance management, and leadership development for enterprise UR leadership and staff.
  10. Conducts regular audits and quality reviews to ensure compliance with regulatory requirements, payer expectations, and organizational standards.
  11. Develops escalation pathways and support structures for complex cases, difficult payer interactions, and high-risk authorization issues.
  12. Leads enterprise education initiatives related to documentation integrity, medical necessity standards, payer trends, and authorization best practices.
  13. Collaborates with Information Technology and EHR leadership to optimize utilization review workflows, reporting capabilities, automation opportunities, and data integrity.
  14. Supports organizational growth initiatives, acquisitions, new program development, and expansion strategies through scalable utilization management processes.
  15. Participates in executive meetings, operational reviews, and strategic planning initiatives as a key organizational leader.
  16. Maintains strict confidentiality of all company, departmental, patient, payer, and healthcare provider information.
  17. Reports enterprise risks, payer concerns, and operational barriers to executive leadership with recommendations for resolution and mitigation.

Education and Experience
Bachelor's degree required, master's degree in nursing, Healthcare Administration, Business Administration, or related healthcare field preferred. Clinical licensure preferred (RN, LCSW, LPC, LMFT, or comparable behavioral health licensure). Requires a minimum of seven (7) years of progressive Utilization Review leadership experience within behavioral health, including large multi-site or enterprise oversight responsibilities. Previous experience developing KPIs, reporting analytics, dashboards, and executive-level operational presentations is required.
Physical Requirements
  • While performing the duties of this job, the employee must communicate with internal and external stakeholders and vendors.
  • Tolerant to various noise levels: noise level in the work environment varies - may be quiet to moderate noise levels.
  • Job performance will require the ability to move throughout the building as well as sit or remain stationary for extended periods of time.
  • While performing the duties of this job, the employee may be required to talk or hear, sit, stand, walk, and reach.
  • Ability to travel by various forms of transportation, including automobiles and airplane.

Additional Requirements
  • Position requires incumbent to have a valid driver's license and acceptable driving record.
  • Clearance of TB test, and any other mandatory state/federal requirements.

Skill Competencies
  • Demonstrates executive leadership and strategic planning capabilities.
  • Demonstrates the ability to lead enterprise-wide operational change and process improvement initiatives.
  • Demonstrates extensive knowledge of behavioral health levels of care, medical necessity criteria, payer operations, reimbursement methodologies, and regulatory requirements.
  • Demonstrates experience leading large-scale operational improvement initiatives and enterprise standardization efforts.
  • Demonstrates a strong understanding of managed care contracting, denial management, appeals processes, and payer negotiation strategies.
  • Demonstrates strong financial acumen with understanding of reimbursement, payer strategy, and revenue optimization.
  • Demonstrates ability to successfully function under pressure in critical and rapidly changing situations.
  • Demonstrates ability to effectively manage conflict, escalation, and crisis situations.
  • Demonstrates strong analytical, problem-solving, and decision-making skills.
  • Demonstrates exceptional organizational and project management skills.
  • Demonstrates excellent interpersonal, relationship-building, and executive communication skills.
  • Demonstrates the ability to influence cross-functional teams and build organizational alignment.
  • Demonstrates a prominent level of discretion, professionalism, and accountability.
  • Demonstrates strong diligence and follow-through.
  • Demonstrates proficiency with Microsoft Office programs, reporting systems, EHR platforms, and data analytics tools.
  • Consistently demonstrates and models alignment with company mission, values, and leadership expectations.

Odyssey Behavioral Healthcare, LLC provides equal employment opportunities without regard to race, color, creed, ancestry, national origin, ethnicity, sex, gender, sexual orientation, marital status, religion, age, disability, gender identity, genetic information, service in the military, or any other characteristic protected under applicable federal, state, or local law. Equal employment opportunities apply to all terms and conditions of employment. Odyssey reserves the right to modify, interpret, or apply this job description in any way the organization desires. This job description in no way implies that these are the only duties, including essential duties, to be performed by the employee occupying this position. Reasonable accommodations may be made to reasonably accommodate qualified individuals with disabilities. This job description is not an employment contract, implied or otherwise. The employment relationship remains "At-Will."

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