Utilization Management Operations Lead

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee and maintain operational and compliance activities for the Utilization Management department.

• Initiate essential process modifications and pinpoint discrepancies and gaps within the department.

• Employ process controls to achieve operational excellence.

• Collaborate with UM leadership to mitigate identified compliance risks.

• Utilize process improvement frameworks to foster continuous development.

• Evaluate data to ensure alignment with compliance, regulatory, and operational mandates.

• Assist in implementing process changes stemming from recognized opportunities.

• Partner with analytics, Physical Health and Behavioral Health clinical teams, compliance, and regulatory teams.

• Confirm that regulatory content is accurately represented in datasets and validated.

• Support implementations through systematic and measurable actions.

• Contribute to regulatory, accreditation, and compliance business objectives.

• Aid in drafting UM and Clinical responses for NQTL data and narrative submissions.

• Foster and manage relationships to enhance standardization and interdepartmental cooperation.

• Provide Clinical and UM assistance for parity-related internal compliance workgroups.

• Define and employ outcome measurements with relevant departments.

• Facilitate the execution of process improvements, business rules, products, and delegations.

• Support change management initiatives impacting the department.

• Assist with annual product filing analysis and UM strategy recommendations from a parity perspective.

• Perform additional job duties as needed.

⛳️ Requirements

• A Bachelor’s degree in healthcare, population health, or a related field, or equivalent years of relevant experience is required.

• At least five (5) years of experience in Utilization Management or related responsibilities is necessary.

• Prior experience with quality control and/or process standards is preferred.

• Expertise in federal and state laws and regulations is essential.

• Proficiency in Microsoft Office Suite, including Word, Excel, PowerPoint, Outlook, and Visio.

• Capability to analyze processes across various functional areas.

• Ability to work both independently and as part of a team.

• Understanding of ROI and risk mitigation.

• Proven knowledge in change management and continuous improvement leadership.

• Skill in gathering data and generating insightful analysis.

• Ability to review and apply evidence-based trends.

• Excellent oral, written, and interpersonal communication skills.

• Strong familiarity with NCQA and/or CMS, accreditation and audit standards, regulatory reporting, and compliance requirements.

• Exceptional attention to detail and time management abilities.

• Strong problem-solving capabilities.

• Effective listening and critical thinking skills.

• Current, unrestricted Registered Nurse (RN) licensure is preferred.

• Six Sigma or project management certifications are preferred.

• General office environment; may require prolonged periods of sitting or standing.

🏝️ Benefits

• Base salary range of $83,000.00 - $132,800.00.

• Potential eligibility for a bonus linked to company and individual performance.

• Comprehensive and substantial total rewards package.

• Support for employee total well-being.