AVP, Utilization and Care Management Strategy (Medicaid)

Location: Remote nationwide within the United States; occasional travel to hirify.global offices for training or meetings may be required.

Salary: $203,400–$279,800 per year, plus eligibility for a bonus incentive plan.

Company

hirify.global is a U.S. healthcare company providing insurance and healthcare services to Medicare and Medicaid members, families, individuals, military personnel, and communities.

What you will do

• Lead enterprise Medicaid utilization and care management strategy, including prior authorization, clinical policy governance, medical expense strategy, site-of-care optimization, and affordability initiatives.
• Establish strategic direction, governance routines, performance expectations, and enterprise priorities in partnership with operational leaders.
• Integrate authorization, utilization, claims, denials, appeals, care management, quality, and member risk data to identify opportunities for earlier intervention and improved care coordination.
• Partner with clinical, operational, financial, actuarial, network, analytics, quality, payment policy, payment integrity, and Medicaid market leaders to align strategy and scale effective solutions.
• Develop executive scorecards, business cases, ROI frameworks, savings validation approaches, and performance management processes.
• Shape vendor and external partner strategies while supporting regulatory alignment, health equity, access to care, whole-person health, and responsible healthcare resource stewardship.

Requirements

• 10+ years of leadership experience in Medicaid, managed care, utilization management, care management, clinical strategy, affordability, medical cost management, population health, or clinical operations.
• Licensed clinical background, such as MD, DO, RN, NP, PA, PharmD, LCSW, or another relevant clinical credential.
• Experience developing strategy, governance models, performance frameworks, and cross-functional initiatives in complex healthcare environments.
• Strong understanding of Medicaid managed care, state and federal regulations, utilization and care management models, clinical policy, provider delivery systems, population health, and medical expense drivers.
• Experience leading enterprise, segment-wide, or multi-market initiatives and influencing senior stakeholders in a complex matrixed organization.
• Bachelor’s degree in a relevant field or equivalent relevant experience; strong analytical, executive communication, stakeholder management, and change leadership skills.

Nice to have

• Physician leadership experience in managed care, Medicaid, utilization management, care management, medical policy, or clinical affordability.
• Advanced degree in medicine, nursing, public health, healthcare administration, business administration, health policy, finance, or a related field.
• Multi-state Medicaid managed care experience.
• Experience with prior authorization optimization, transitions of care, complex care management, gold carding, site-of-care optimization, payment integrity, or vendor strategy.

Culture & Benefits

• Remote work from a dedicated space that protects member PHI and HIPAA information.
• Home internet service must provide at least 25 Mbps download and 10 Mbps upload speeds.
• 40-hour scheduled workweek with paid time off, company and personal holidays, and paid parental and caregiver leave.
• Medical, dental, vision, disability, life insurance, and 401(k) retirement savings benefits.
• Whole-person wellness support and additional employee benefit opportunities.