VP, Clinical Operations

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com .

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• Lead the strategic redesign, operational performance, and day-to-day management of the health plan’s Utilization Management function across Medicaid, Commercial, and Medicare lines of business.
  
• Provide senior clinical and operational leadership for the health plan’s Utilization Management department and function across Medicaid, Commercial, and Medicare lines of business. Accountable for UM strategy, day-to-day operational performance, Medical Director leadership, and oversight of vendors supporting utilization management activities.
  
• Ensure clinically appropriate, compliant, efficient, and member-centered UM operations while innovating change across the function to improve access to medically necessary care, strengthen provider experience, advance member experience and health outcomes, promote affordability, and support the health plan’s clinical, quality, regulatory, and business objectives.
  
• Provide executive oversight for approximately 250 employees, including an 8-member Medical Director team, and external utilization management vendors.
  
• Responsible for building a modern, data-driven, compliant, and member-centered UM operating model that improves access to medically necessary care, strengthens provider experience, advances affordability, and positions UM as a differentiating capability that supports growth and market competitiveness.

Principal Accountabilities

• Strategic Thinking. Adapts to changes in the marketplace. Identifies short and long-term functional goals and strategies. Leads change efforts in redefining how to serve customers.
  
• Organizational Development. Implements organization structure and communicates roles/accountabilities. Identifies workforce gaps and develops talent to fill gaps. Identifies key talent/high potentials and informs Senior Leaders. Recognizes and celebrates success.
  
• Transparent Communication. Communicate business strategy with functional leaders to facilitate change across the enterprise; ensure that employees understand how what they do links to strategy. Frequently cascades information up and down the organization. Models transparency with dashboard/metrics. Clearly and effectively communicates.
  
• Lives the Values. Makes decisions that support the values. Demonstrates the values in daily activities. Holds Directors accountable for living the values. Places Company and team above self.
  
• Continuous Improvement. Sets stretch goals that improve performance. Takes measured risks and develops contingency plans, when needed. Develops new ways of accomplishing work that supports innovation efforts. Proactively works to improve processes. Promotes and rewards efforts to make the enterprise-wide work environment open to new ideas and thinking. Continuously enhances and improves own contribution.
  
• Accountability. Holds self and team accountable for achieving results. Identifies and removes obstacles to getting things done. Makes decisions in timely manner. Displays ability to make difficult decisions.
  
• Direct and matrixed leadership for approximately 250 UM professionals, including clinical reviewers, non-clinical support staff, supervisors, managers, operational leaders, and Medical Directors. Provide day-to-day executive leadership for UM operations, ensuring timely, accurate, and clinically appropriate decisions in accordance with Medicaid, Commercial, and Medicare regulatory requirements, accreditation standards, plan policies, evidence-based criteria, benefit design, and product-specific coverage rules. Build and sustain a high-performing leadership structure across UM operations and the Medical Director team, with clear accountability for productivity, quality, turnaround times, service levels, escalation management, and staff engagement. Partner with Medical Directors to strengthen clinical decision-making, peer review processes, inter-rater reliability, medical policy application, denial rationale quality, and provider communication.
  
• Oversight of an 8-member Medical Director team responsible for medical necessity determinations, peer-to-peer reviews, appeals support, policy review, and clinical governance. Strengthen clinical governance and Medical Director effectiveness. Lead Medical Directors in advancing medical necessity decision-making, peer review, inter-rater reliability, clinical policy application, denial rationale quality, provider communication, and escalation resolution.
  
• Accountability for vendor performance, delegated UM activities, service levels, quality outcomes, turnaround times, compliance, and contractual performance guarantees.
  
• Operational responsibility across core UM functions for Medicaid, Commercial, and Medicare products, including prior authorization, concurrent review, retrospective review, discharge planning linkages, medical necessity review, denials management, appeals support, provider escalations, and line-of-business-specific regulatory reporting.
  
• Ensure that UM models are appropriately tailored to each line of business, including Medicaid state contract requirements, Commercial employer and purchaser expectations, and Medicare Advantage regulatory, audit, and coverage determination requirements.
  
• Accountability for UM Centers of Excellence, including City of New York Centers of Excellence, that standardize best-practice workflows, specialized expertise, governance, training, quality monitoring, and performance improvement across all lines of business. Build Centers of Excellence and scalable enterprise capabilities. Design and advance UM Centers of Excellence, including City of New York Centers of Excellence, to standardize best practices, specialized expertise, workflows, training, quality monitoring, and performance improvement across all lines of business.
  
• Lead enterprise transformation of the UM operating model, aligning people, process, technology, clinical policy, vendor capabilities; design and advance UM Centers of Excellence, including City of New York Centers of Excellence, for priority areas such as prior authorization, concurrent review, post‑acute review, specialty care review, Medical Director review, appeals support, vendor oversight, and provider escalation management; improve consistency, compliance, affordability, and member/provider experience. Set enterprise UM strategy and operating discipline. Lead the clinical, operational, technology, governance agenda for Utilization Management across Medicaid, Commercial, and Medicare to improve consistency, compliance, affordability, and member/provider experience. Improve UM performance, access, and service delivery. Drive measurable improvements in authorization turnaround times, case throughput, documentation quality, provider escalations, appeal outcomes, and timely access to clinically appropriate care.
  
• Drive process improvement initiatives to reduce administrative burden, eliminate bottlenecks, standardize workflows, improve documentation quality, and enhance coordination with Care Management, Quality, Network, Provider Relations, Claims, Compliance, Appeals and Grievances, Pharmacy, and Medical Economics.
  
• Modernize UM technology and case management capabilities. Partner across technology, analytics, and operations to update UM platforms, case management workflows, automation, provider-facing tools, decision support, evidence libraries, dashboards, and reporting infrastructure to manage cases more efficiently and improve transparency. Innovate change to improve member experience and health outcomes. Lead transformation initiatives that reduce administrative friction, support timely care transitions, improve quality and equity, and use data to identify opportunities that strengthen member outcomes and clinical impact.
  
• Launch cost‑of‑care transformation programs that improve utilization performance, strengthen service delivery, and support market cost competitiveness. Advance affordability and cost‑of‑care transformation. Use analytics, utilization trends, medical cost data, provider patterns, and operational metrics to improve appropriateness of care, reduce avoidable utilization, and support market cost competitiveness. Develop and monitor a comprehensive UM scorecard with key performance indicators such as authorization turnaround time, denial rates, appeal overturn rates, provider escalations, productivity, medical director review volume, compliance audit results, vendor performance, and member/provider experience indicators. Use analytics, utilization trends, medical cost data, provider patterns, and operational metrics to identify opportunities for improved affordability, quality, access, and appropriateness of care.
  
• Oversee vendor performance management, including contract expectations, delegated oversight, operational reporting, corrective action plans, service‑level compliance, issue resolution, and executive business reviews. Ensure disciplined vendor oversight and accountability. Lead the UM vendor management function, including delegated oversight, service‑level performance, quality outcomes, turnaround times, corrective action plans, contractual guarantees, issue resolution, and executive business reviews.
  
• Ensure UM policies, procedures, criteria, and committee governance are current, compliant, consistently applied, and aligned with applicable federal requirements, state Medicaid contract requirements, Commercial benefit and employer group obligations, Medicare Advantage coverage rules, accreditation standards, and the health plan’s clinical strategy.
  
• Lead line‑of‑business‑specific UM governance, ensuring appropriate differentiation in clinical criteria, benefit interpretation, member notices, authorization requirements, appeal pathways, delegated vendor oversight, and reporting across Medicaid, Commercial, and Medicare.
  
• Lead readiness for regulatory, accreditation, and internal audits related to Utilization Management, delegated vendor oversight, medical necessity determinations, timeliness, member notices, and appeals support. Maintain regulatory, accreditation, and audit readiness. Ensure UM policies, procedures, criteria, notices, committee governance, delegated vendor oversight, and line‑of‑business requirements are current, compliant, consistently applied, and audit‑ready.
  
• Partner with Medicaid, Commercial, and Medicare business leaders to align UM operations with product strategy, affordability goals, quality priorities, state and federal requirements, growth objectives, provider network strategies, and member experience expectations. Partner with technology, analytics, and operations leaders to modernize UM capabilities, including workflow tools, provider portals, rules‑based automation, evidence libraries, dashboards, and decision‑support capabilities.
  
• Advance market share and competitive differentiation by upgrading UM service delivery, reducing provider and member abrasion, improving turnaround times, strengthening provider trust, and supporting purchaser, regulator, and member expectations.
  
• Serve as a senior clinical operations leader and change agent, communicating transformation priorities, managing stakeholder alignment, and ensuring disciplined execution across business, clinical, and vendor partners.

Qualifications

• Bachelor’s degree required; MBA or advanced degree preferred.
  
• Clinical license such as MD, DO, or other relevant unrestricted physician license required.

Relevant Work Experience, Knowledge, Skills, and Abilities

Required:

• 10+ years of progressive physician leadership experience, including significant experience in utilization management, medical management, clinical operations, or health plan operations.
  
• 8 – 12+ years in commercial health insurance and/or employee benefits with demonstrated experience in product strategy, consulting, distribution strategy, or strategic sales advisory.
  
• 7+ years of senior leadership experience building and managing multi-disciplinary teams.
  
• Demonstrated experience leading large clinical or operational teams in a managed care, health plan, provider-sponsored plan, or delegated services environment; and leading Medical Directors, clinical governance structures, physician review workflows, and interdisciplinary UM decision-making processes.
  
• Strong understanding of UM operations, including prior authorization, concurrent review, medical necessity criteria, denials, appeals, peer-to-peer review, regulatory timeframes, and delegated oversight.
  
• Proven ability to lead UM vendor management, delegated oversight, contractual service levels, corrective actions, executive vendor relationships, and regulatory compliance monitoring.
  
• Experience using data, dashboards, and operational metrics to drive performance improvement, compliance, quality, and medical cost management.
  
• Deep knowledge of Medicaid, Commercial, and Medicare Advantage products, including product-specific UM requirements, regulatory timeframes, benefit structures, coverage determination rules, appeals and grievances processes, delegated vendor oversight, and audit readiness expectations.
  Preferred Qualifications:
  
• Lean, Six Sigma, process improvement, or transformation leadership experience.
  
• Experience with NCQA, URAC, CMS, state Medicaid requirements, Commercial accreditation and purchaser expectations, delegated oversight, and audit readiness.
  
• Experience leading UM operations across multiple lines of business, with demonstrated ability to standardize enterprise processes while preserving product-specific compliance, benefit, and population-health requirements.
  
• Experience implementing/optimizing UM platforms, provider portals, rules engines, workflow automation, or analytics tools.
  
• Experience building Centers of Excellence, including City of New York Centers of Excellence, shared services, centralized clinical operations, or enterprise capability models that improve consistency, scalability, quality, and business performance.
  

Additional Information

• Hiring Range: $325,000-$400,000

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Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual’s circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN,