About this role
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).