SCOPE OF ROLE

The AVP of Clinical Performance oversees the strategy, operations, and performance of Delegated Utilization Management (UM) and Care Management (CM) programs that ensure healthcare services are medically necessary, cost-effective, and aligned with payer and regulatory requirements. This role will be directly responsible for the management of clinical capabilities related to delegated utilization management and delegated care management across multiple health plan clients in the California Medi-Cal, Medicaid delegated services markets.

This is a work from home position based in California or the Pacific Time Zone.

DUTIES & RESPONSIBILITIES

Core Leadership Responsibilities

• Drive quality, efficiency, and consistency using internal and external benchmarks
• Lead and develop UM/CM Directors; set clear direction, accountability, and performance expectations
• Ensure standardized operations and workflows
• Collaborate with operational and medical director leadership of affiliate partners
• Partner with finance and clinical leaders to align staffing, skill mix, and resources
• Foster a culture of high performance, continuous improvement, and regulatory excellence
• Oversee daily UM and CM operations to ensure effective care coordination and utilization review

Utilization Management

• Lead UM programs including prior authorization, concurrent, retrospective review, and medical necessity determinations
• Ensure compliance with federal, state, health plan and NCQA requirements
• Manage authorization turnaround times to exceed payer standards
• Oversee denial processes, notifications, and timeliness requirements
• Identify opportunities to reduce unnecessary utilization while maintaining quality
• Support value-based contract performance through effective utilization controls
• Partner with CMO and Medical Directors to meet regulatory and compliance standards
• Support internal and health plan audits and ensure proper clinical review hierarchy

Care Management

• Oversee inpatient and complex care management programs
• Ensure compliance with federal, state, and NCQA care management standards
• Establish standardized workflows, care plans, and documentation practices
• Integrate care management into physician workflows and primary care teams
• Participate in and support internal and health plan audits

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s Degree in business, healthcare administration, nursing, or a related field is required; MBA/MHA and/or clinical degree is preferred. 
• Minimum of ten (10) years of MSO operations experience, with at least five (5) years in a national/regional management role required.
• Experience in change management and process improvement required.
• Registered Nurse license is preferred.

PROFESSIONAL COMPETENCIES

• Ability to operate effectively in a matrixed environment
• Strong clinical leadership, communication, and relationship-building skills
• Results-driven, with the ability to translate strategy into measurable outcomes
• Proven success leading organizational change and performance improvement
• Strong collaboration and cross-functional alignment capabilities
• Deep clinical acumen with expertise in utilization review and management
• Strong analytical and presentation skills
• Experience developing and leading governance models for care and utilization management