[Hiring] Utilization Management Admin & Operations Program Specialist @Amerihealth Caritas

Role Description

As part of the Utilization Management (UM) Administrative Team, the UM Administrative and Operations Program Specialist is responsible for the coordination and ongoing monitoring of UM program objectives, including support of performance improvement projects for service and clinical activities, integrating the quality improvement and efficiencies into all UM department activities. This role implements and supports the overall implementation of UM programs that meet or exceed applicable State, Federal and NCQA standards. Under the direction of UM Leadership, you will support new and existing business through policy writing and updates, development of program documents and updates, development of processes, report development and validation of reports prior to submission. This position also represents UM at Quality meetings to present changes, documents and work-plan required items.

Work Arrangement

• Remote role
• Monday through Friday from 8:30 AM EST to 5:00 PM EST

Responsibilities

• Support successful development and evaluation of an annual UM work plan and program description by collaborating with corporate and market UM leadership and other areas throughout the organization as necessary.
• Request reports both standing and ad-hoc, support validation of the data upon report completion, identify, resolve and/or escalate problematic UM areas to UM leadership that may impact the department’s ability to achieve annual goals.
• Participate in the development, implementation and maintenance of UM policies and procedures.
• Work professionally and efficiently with all functional areas in meeting organizational and departmental UM goals.
• Collaborate with each Market to ensure policies are created and/or updated in accordance with State, Federal, regulatory and accrediting body’s standard requirements.
• Ensure timely submission of policy updates, reports, and program documents to appropriate committee for approval.
• Participate on Quality Committees to present reports, policies and/or program documents that are consistent in meeting regulatory and accrediting body requirements.
• Initiate review and submission process for state approval of program documents when state approval is required.
• Maintain tracking and version control for all policies and standard operating procedures.
• Participate in New Business Implementation process as assigned to assist with development of program documents, policies, workflows.
• Serve as a resource for utilization management teams during new business go-live.

Qualifications

• Associate’s Degree or equivalent work experience required.
• Bachelor’s Degree preferred.
• Minimum of 3 years in clinical or service quality improvement required.
• Minimum of 3 years in healthcare delivery required.
• Managed health care experience preferred.
• Successful management of NCQA accreditation survey preferred.
• Experience with medical management systems, CMS interoperability, Electronic Health Records such as Epic, Cerner, Jiva.

Skills

• Excellent organizational, analytical and interpersonal skills.
• Excellent written and verbal communication skills.
• Ability to work successfully within all levels of the organization.
• Ability to design, develop and implement projects to address financial, quality and service improvements.
• Proficient PC skills in a Windows based environment.
• Ability to read contracts or legal documents and extract key language to support program and policy development.

Benefits

• Flexible 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.