VP, Managed Care

Location: 100% Remote, U.S.

Company Size: 100–200 employees

Opportunity

Newly created executive role reporting directly to the CEO, responsible for building and leading the organization’s Managed Care function across Medicare Advantage (MAPD).

The VP will oversee Risk Adjustment, Utilization Management, and Care Management, with accountability for clinical and financial performance, regulatory compliance, medical cost, quality, and member outcomes.

Why This Role

• Build and shape the Managed Care function from the ground up.
• Lead a team of 7 across Risk Adjustment, Utilization Management, and Care Management.
• Develop an integrated operating model across previously separate functions.
• Drive measurable improvement in risk-adjusted revenue, utilization, medical cost, quality/Stars, and member outcomes.
• Work closely with executive leadership, Finance, Actuarial, Analytics, Clinical Operations, Network, Quality, Compliance, and other key functions.
• Performance-focused leadership role—not a contract-negotiation position.

Key Responsibilities

• Set the strategy and operating model for Risk Adjustment, Utilization Management, and Care Management.
• Optimize Medicare Advantage risk adjustment, diagnosis capture, documentation, coding, and encounter data.
• Oversee UM programs, including authorization, utilization review, clinical appropriateness, and cost management.
• Lead care management and population health programs for high-risk, complex, and high-cost members.
• Integrate Risk, UM, and Care Management to identify opportunities to improve outcomes and plan economics.
• Partner with Finance, Actuarial, Analytics, Network, and Clinical teams to identify and reduce avoidable medical cost and utilization.
• Align managed care programs with Medicare Advantage quality/Stars objectives.
• Ensure CMS regulatory and audit readiness, including RADV.
• Establish executive dashboards, performance metrics, and ROI measurement.
• Build a high-performing organization and develop leaders, talent, processes, and infrastructure to support growth.

Measures of Success

• Improved risk-adjusted revenue, RAF/HCC performance, and coding accuracy.
• Reduced avoidable utilization and medical expense.
• Improved management of high-risk/high-cost members and care outcomes.
• Strong UM performance and regulatory compliance.
• Improved provider engagement and performance.
• Alignment across Risk Adjustment, UM, Care Management, and Quality/Stars.
• Demonstrated ROI from managed care initiatives.
• Scalable infrastructure supporting Medicare Advantage growth.

First 12 Months

• Establish an integrated Risk Adjustment, UM, and Care Management strategy.
• Assess current operations and establish measurable performance targets.
• Implement executive dashboards covering risk, utilization, medical cost, quality, and care management.
• Strengthen risk adjustment and provider documentation initiatives.
• Evaluate and improve UM effectiveness and utilization outcomes.
• Build an integrated high-risk/high-cost member strategy and UM-to-Care Management referral model.
• Identify and prioritize the highest-value medical cost opportunities.
• Strengthen CMS/RADV readiness and establish a multi-year technology and analytics roadmap.

Required Qualifications

• 10+ years of progressive healthcare leadership experience.
• Significant Medicare Advantage managed care experience.
• Leadership experience across at least two of: Risk Adjustment, Utilization Management, Care Management, Population Health, Medical Management, Medical Economics, or Value-Based Care.
• Strong knowledge of CMS Medicare Advantage requirements.
• Demonstrated ability to improve both clinical outcomes and financial performance.
• Experience leading complex clinical/managed care operations and cross-functional teams.
• Strong analytical, strategic, executive communication, and organizational leadership skills.
• Bachelor’s degree required; master’s degree strongly preferred.

Preferred

• MAPD and Medicare Part D experience.
• CMS-HCC, encounter data, RADV, and CMS audit experience.
• Experience with Medicare Advantage Stars and quality programs.
• Value-based care, delegated risk, or provider performance experience.
• Experience with clinical analytics, predictive modeling, automation, or AI-enabled workflows.
• Experience in a health plan, IPA, ACO, integrated delivery system, or value-based care organization.