About this role
Job description
Key Responsibilities
- Data Analysis & Reporting: Analyze utilization trends, claims data, and pharmacy data to identify cost-containment opportunities.
- Workflow Optimization: Document, review, and enhance UM processes (intake, concurrent review, appeals).
- System Enhancement: Define business requirements for IT solutions and conduct user acceptance testing (UAT) for UM software.
- Regulatory Compliance: Ensure all UM processes comply with state/federal regulations and accreditation standards.
- Cross-functional Collaboration: Act as a liaison between clinical staff (nurses, medical directors) and IT/leadership.
Required Skills and Qualifications
- Experience: 3-5+ years in UM, care management, or managed care settings.
- Technical Proficiency: Strong SQL skills, data visualization tools (e.g., Tableau, Power BI), and electronic health records (EHR/EMR).
- Knowledge: Deep understanding of healthcare coding (ICD-10, CPT), claims, and insurance regulations.
- Education: Bachelor’s degree in Healthcare Administration, Nursing, or related field.
- Clinical Background: RN or LPN license is highly preferred for clinical data interpretation.
Common Tools Used
- SQL and relational databases.
- Data analysis software (Excel, SAS, SQL).
- Workflow modeling tools (Visio).
- Reporting platforms (Tableau, Power BI).