• Provide high-level oversight and a "guiding hand" over 16 state, private, and federal (VA) appeal contracts.
• Manage and monitor contract deliverables, troubleshoot issues, and formulate budgets.
• Respond to RFPs and collaborate with senior management / CEO to report on program metrics.
• Lead a team of 30 through an upcoming operational system transformation.
• Attend key industry conferences (e.g., URAC) to network and drive business development.

Requirements/Must Haves (years? degree? cert? etc.):

• Registered Nurse (RN) license.
• Bachelor’s degree (minimum) with 5+ years of supervisory/leadership experience.
• Must have deep expertise with Independent Review Organizations (IROs) and URAC standards/guidelines.
• Strong background in utilization review, appeal formulation, and managed care.
• No bedside-only experience—must have managed care, insurance, or state-level appeal background.

Nice to have:

• Master’s degree.
• Experience working with or managing New York State health contracts, Medicaid, or large union groups (e.g., 1199).

Ideal candidate profile: A self-starter with an insurance or managed care plan background (e.g., Blue Cross, Centene) who has overseen complex appeal operations and contract deliverables.
Soft skills/Personality traits: Strong leadership presence, analytical, comfortable speaking with C-suite executives, and unafraid of hard work or leading transformative change.

GENERAL RESPONSIBILITIES:

This leader will direct the management of state, federal and private Independent Review Organization (IRO) operations within the Federal & State Healthcare Assessment Division (FSHCA), consistent with Strategic Plan and Corporate Goals. This individual will provide clinical &/or claims, managerial and industry expertise and assist the VP and Associate VP with business development for federal, state and private lines of business, including the introduction of new software solutions, products and services, staffing and proposal responses. This individual will provide leadership across both Corporate Programs Departments managing multiple client contracts, including primary New York, Kentucky, Pennsylvania state associated contracts, Veterans Affairs and Abu Dhabi contracts.

DUTIES:

1. Provide hands-on program guidance and support to IRO Directors. This includes monitoring daily performance metrics, contract deliverables oversight, staff assignments and leadership coverage.

2. Report routinely to the Vice President and Associate Vice President (FSHCA) on department activities, including contract deliverables, program development, and contractor communications.

3. Direct the day-to-day activities of staff and consultants, and overall resource allocation management. Manage program budgets and oversee staff development, training, and communication plans.

4. Establish and implement operational and strategic plans. Mitigate risks and assess program performance.

5. Liaison to internal and external stakeholders. Manage customer relationships in close coordination with governmental and private program managers.

6. Provide subject matter expertise and adaptive leadership to ensure the completion of current, and the implementation of new project activities.

7. Support proposal writing and the creation of technical documents.

8. Monitor contract expiration dates and work with the proposals department to avoid lapses.

9. Coordinate with Directors to maintain department training records, insure cross-training of all staff and compliance with URAC / ISO training requirements

10.Promote and maintain ISO/URAC standard and participatein/prepare reports for audits

11. Manage the creation, development, and implementation of technological programs and methodologies

12. Advise the department on complaints/non-conformities in compliance with QA/QC policies and compliance with QMS Reporting

13. Mentor and develop department leaders, facilitate conference attendance and offsite business activities. Provide training and leadership development opportunities.

14. Participate in leadership activities, including Full Management meetings, leadership training, and events.

15. Other activities, as may be deemed necessary.

QUALIFICATIONS:
1. Demonstrated knowledge of IRO activities including provider, MCO and patient appeals processes.

2. Knowledge of IRO Policies and State External review regulations.

3. Knowledge and experience with collaborative project management software, electronic documents, and design.

4. Ability to problem solve and work collaboratively with peers, medical, analytical, and administrative support staff.

5. Well-developed interpersonal communication skills, and ability to write and communicate well in all media.

6. Ability to work independently with little supervision.

7. Ability and desire to be flexible, innovative, and creative while multi-tasking.

8. Ability to meet deadlines in time sensitive environment including off-hours coverage.

EDUCATION & EXPERIENCE:

1. Licensed, Registered Nurse (any state), required & graduate of an approved Registered Professional Nurses training program, required

2. Bachelor’s Degree in Nursing or healthcare field, required. Master’s Degree, preferred.

3. A minimum of 5 years’ supervisory/managerial experience, required.