Utilization Management Operations Lead

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $83k - $132.8k / year

⏰ Full Time

🟠 Senior

⚙️ Operations

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Maintain and oversee operational and compliance activities supporting the Utilization Management department • Drive key process changes and identify gaps and variances across the department • Use process controls to achieve operational excellence • Work with UM leadership to close identified compliance risks • Apply process improvement frameworks to drive continuous improvement • Assess data for alignment with compliance, regulatory, and operational requirements • Support process changes resulting from identified opportunities • Collaborate with analytics, Physical Health and Behavioral Health clinical teams, compliance, and regulatory teams • Ensure regulatory content is represented in datasets and validated • Assist with implementations using systematic and measurable actions • Support regulatory, accreditation, and compliance business goals • Assist in creating UM and Clinical responses for NQTL data and narrative submissions • Build and manage relationships to improve standardization and interdepartmental collaboration • Provide Clinical and UM support for parity-related internal compliance workgroups • Define and utilize outcome measurements with appropriate departments • Support implementation of process improvements, business rules, products, and delegations • Support change management initiatives affecting the department • Assist with annual product filing analysis and UM strategy recommendations from a parity perspective • Perform other job duties as requested

🎯 Requirements

• Bachelor’s degree in healthcare, population health or related field, or equivalent years of relevant work experience is required • Minimum of five (5) years of experience in Utilization Management or experience related to the role’s responsibilities is required • Previous experience with quality control and/or process standards is preferred • Subject matter expertise in federal and state laws and regulations • Proficient use of Microsoft Office Suite, including Word, Excel, PowerPoint, Outlook, and Visio • Ability to analyze processes across multiple functional areas • Ability to work independently and within a team environment • Understanding of ROI and risk avoidance • Demonstrated change management and continuous improvement leadership knowledge • Ability to gather data and create meaningful analysis • Ability to review and implement evidence-based trends • Strong oral, written, and interpersonal communication skills • Strong understanding of NCQA and/or CMS, accreditation and audit standards, regulatory reporting, and compliance requirements • Strong attention to detail and time management skills • Effective problem-solving skills • 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 be required to sit or stand for extended periods of time

🏖️ Benefits

• Base salary range of $83,000.00 - $132,800.00 • May qualify for a bonus tied to company and individual performance • Substantial and comprehensive total rewards package • Employee total well-being support