AVP Medical Management

Number of Positions In Requisition
1


Job Details
The AVP, Medical Management serves as a key member of the Healthcare Management leadership team and partners closely with the Chief Medical Officer (CMO)/SVP to provide strategic oversight of Medical Management operations, including Precertification, Inpatient Services, Provider Appeals, Durable Medical Equipment (DME), and Ancillary Services. This position is responsible for driving operational excellence, regulatory compliance, quality outcomes, and cost-effective healthcare management across the organization.

Provides oversight of utilization management programs, delegated vendor performance, care management systems, regulatory reporting, and business continuity planning. The role is accountable for ensuring compliance with state and federal requirements, including reporting to regulatory agencies such as the Department of Human Services (DHS/DPW), Pennsylvania Insurance Department (PID), and Department of Health (DOH). Through strong leadership, collaboration, and data-driven decision-making, this position advances organizational goals related to quality, service, member outcomes, operational performance, and responsible healthcare resource management.

Job Description

Summary
The AVP, Medical Management serves as a key member of the Healthcare Management leadership team and partners closely with the Chief Medical Officer (CMO)/SVP to provide strategic oversight of Medical Management operations, including Precertification, Inpatient Services, Provider Appeals, Durable Medical Equipment (DME), and Ancillary Services. This position is responsible for driving operational excellence, regulatory compliance, quality outcomes, and cost-effective healthcare management across the organization.

Provides oversight of utilization management programs, delegated vendor performance, care management systems, regulatory reporting, and business continuity planning. The role is accountable for ensuring compliance with state and federal requirements, including reporting to regulatory agencies such as the Department of Human Services (DHS/DPW), Pennsylvania Insurance Department (PID), and Department of Health (DOH). Through strong leadership, collaboration, and data-driven decision-making, this position advances organizational goals related to quality, service, member outcomes, operational performance, and responsible healthcare resource management.

Job Duties
- Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

- Provide leadership and strategic direction for all Medical Management functions.

- Develop and execute initiatives that support quality, affordability, regulatory compliance, member experience, and organizational performance goals.

- Oversee operational performance, utilization trends, medical spend, and resource management to identify opportunities for improvement and cost savings.

- Lead regulatory, contractual, and accreditation compliance efforts, including oversight of reporting requirements and submissions to state and federal agencies.

- Direct the development and implementation of performance metrics, dashboards, and analytics to support business decision-making and continuous improvement.

- Oversee Care Management systems, business continuity planning, and delegated vendor performance to ensure operational effectiveness and compliance.

- Lead Utilization Management governance activities, including committee oversight, policy development, and program evaluation.

- Build, develop, and inspire high-performing leadership teams while fostering a culture of accountability, innovation, and collaboration.

- Partner with executive leaders across the organization to drive enterprise initiatives and achieve strategic objectives.

Minimum Qualifications
- Bachelor’s Degree in Nursing, Healthcare Administration, Business Administration, Public Health, or a related field.
- 10 years or more years of progressive leadership experience in managed care, health plan operations, healthcare administration, Medical Management, Utilization Management, or a related healthcare environment.
- Demonstrated expertise in Utilization Management, healthcare operations, regulatory compliance, accreditation standards, and healthcare quality programs.

- Proven experience leading multidisciplinary teams and driving organizational performance in a highly regulated environment.

- Strong financial acumen, including budget development, resource management, and medical cost containment strategies.

- Exceptional communication, relationship management, strategic planning, and decision-making skills.

Preferred Qualifications
- Master’s Degree in healthcare administration (MHA), Business Administration (MBA), Nursing (MSN), Public Health (MPH), or a related field.
- Health plan or payer experience, including Medicaid, Medicare, and/or Commercial lines of business.

- Experience partnering with executive leadership, board committees, regulatory agencies, and external stakeholders

- Knowledge of care management platforms, healthcare analytics, business intelligence tools, and performance reporting methodologies.

- Experience leading enterprise-wide transformation, operational excellence, process improvement, and value-based care initiatives.
- RN - Licensed Registered Nurse_PA - State of Pennsylvania or

- CPHQ - Certified Professional in Healthcare Quality - National Association for Healthcare Quality or

- ACM - Accredited Case Manager - American Case Management Association or

- CCM - Certified Case Manager - Commission for Case Manager Certification or

- CHCQM - Certified Healthcare Quality Management - American Board of Quality Assurance and Utilization Review Physicians or

- FACHE - Fellow of the American College of Healthcare Executives - American College of Health Care Executives

Additional Qualifications

Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift
Workday Day (United States of America)

Worker Sub Type
Regular

Employee Entity
Health Partners Plans, Inc.
Primary Location Address
1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem  colleagues, adjunct faculty, and Jeff Temps ), have access to medical (including prescription) insurance.

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