Vice President of Enterprise Utilization Management ...

Highmark Inc. Join Highmark Inc. in a transformative leadership role as the Vice President of Enterprise Utilization Management Strategy and Excellence. This position is pivotal in shaping and executing a comprehensive strategic vision to enhance Highmark's Enterprise Utilization Management function. As a key leader, you will ensure impactful market positioning and effective cost containment across all lines of business, including Medicare, Medicaid, commercial, and ACA. Your leadership will position Highmark as an industry leader through significant operational transformation aligned with a member-focused strategy. You will oversee an organization managing over 1,000 service level requirements, prioritizing compliance and risk mitigation related to government mandates and regulations. Your role will be central in driving continuous improvement and integrating industry-best practices to meet critical performance and compliance objectives, while also managing UM operations for external health plans and administrators. Key Responsibilities: Architect and execute a multi-year strategic roadmap for Utilization Management, aligning with Highmark's Living Health strategy and establishing Highmark as a market leader. Drive quality programs to enhance decision accuracy and set new performance standards, leveraging strategic partnerships and technology. Identify and expand revenue opportunities through a sophisticated Utilization Management Business Process as a Service (BPaaS) offering, enhancing Highmark's market outreach. Lead collaborative cross-enterprise commitments to ensure high-quality, effective, and well-governed UM operations. Define and guide the technological direction for UM, prioritizing enhancements in automation and digital solutions to streamline processes. Oversee Utilization Management across all business lines and states, ensuring compliance with contractual SLAs and regulatory requirements. Establish an optimized UM workforce strategy, managing staffing models and initiatives for employee engagement across the organization. Implement and oversee a strategic performance framework for Utilization Management, focusing on key metrics to gauge transformation impacts. Provide leadership to direct reports and the broader UM organization, focusing on talent development and performance management. Required Experience: 15+ years in the Health Insurance Industry with a robust understanding of payer operations. 10+ years in Strategic Operational Planning and leading large-scale enterprise-wide transformations. 10+ years in a senior Operational Leadership role within a complex organization. 10+ years of direct healthcare cost containment experience in Payment Integrity, Claims, or Utilization Management. Proven experience in business development and managing substantial P&L responsibilities. Demonstrable success in leading enterprise-wide change initiatives and transformative process improvements. Preferred Experience: 5+ years in a technology leadership role or overseeing technology-driven transformations. 5+ years in quality improvement initiatives across large-scale organizations. 3-5 years of Medicaid experience is preferred. Education Requirements: Bachelor's degree in Nursing, Health Plan Administration, or Business Administration/Management. Substitution Information: May substitute another 4-year degree or 10+ years of substantive experience in a VP of Operations or COO role within the Health Insurance Industry. Preferred Certifications: 2-5 years in technology and prior experience managing Medicaid and clinical teams. PMP or Lean Six Sigma Master Black Belt certification is highly preferred. Travel Requirement: 0% - 25% Position Type: Office- or Remote-based This is a unique opportunity to lead transformative initiatives at Highmark. We are committed to creating a diverse and inclusive environment and encourage all qualified applicants to apply.

Created: 2026-03-10