Vice President Physician Medical Management

Role Overview: The Vice President, Physician Medical Management is responsible for physician leadership and oversight of all medical management programs, with a focus on utilization management, case management, and quality improvement initiatives. This executive ensures alignment of physician leadership with operational efficiency, regulatory compliance, and contractual obligations while advancing a whole-person care model for members.This role is accountable for delivering timely, evidence-based medical determinations and for leading physician engagement across multidisciplinary teams. In close partnership with Enterprise Operations and Clinical Operations, the VP will drive consistency, efficiency, and high-quality outcomes in utilization review, prior authorization, behavioral health reviews, and appeals.The Vice President serves as a key collaborator with stakeholders across the enterprise, identifying opportunities to improve member outcomes, enhance provider partnerships, and manage healthcare costs. The role also provides executive-level input on the development and monitoring of key performance indicators, policies, and protocols to strengthen physician medical management functions.Work Arrangement:

• Remote role

Responsibilities:

• Provides physician leadership in the development of medical management protocols, ensuring high-quality medical decision-making grounded in evidence-based criteria.
• Oversees utilization management processes, including prior authorization, medical necessity reviews, and appeals, ensuring compliance with contractual obligations and regulatory standards.
• Partners with enterprise leadership to align physician-led utilization management with case management and care coordination strategies.
• Ensures adherence to federal, state, and local regulations as well as AmeriHealth Caritas clinical policies and procedures.
• Works closely with behavioral health and quality management teams to achieve contractual obligations and enhance member health outcomes.
• Leads multidisciplinary physician teams, ensuring appropriate resource allocation, operational efficiency, and timely medical determinations.
• Collaborates with stakeholders to analyze clinical and financial data, identifying trends and opportunities to improve the effectiveness of medical management strategies.
• Develops, monitors, and enforces Key Performance Indicators (KPIs) and production metrics to drive accountability and improvement.
• Provides training, education, and leadership to physician medical directors and other clinical leaders.
• Acts as a strategic advisor to executive leadership on emerging trends, regulatory risks, and opportunities in physician-driven medical management.

Education and Experience:

• Minimum of 7 years of direct experience in utilization review, case management, and physician leadership within managed care or health plan environments.

Minimum of ten years of progressive leadership in Medical Management to include Medical Director or senior physician executive roles.Other Skills:

• Strong business acumen and operational mindset with ability to balance clinical quality and cost efficiency.
• Experience with Managed Medicaid programs strongly preferred.
• Proven management experience leading physician teams in utilization management and case management.
• Deep understanding of regulatory standards (NCQA, CMS, state-specific requirements).
• Demonstrated success with provider engagement and network collaboration.
• Exceptional communication and negotiation skills; ability to simplify complex medical concepts for diverse audiences.

Ability to perform effectively in a fast-paced, highly. regulated environment.Your career starts now. We’re looking for the next generation of health care leaders.At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation’s leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.Discover more about us at .Our Comprehensive Benefits PackageFlexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

AmeriHealth Caritas