Utilization Management & Review Specialist

Job Purpose

The Utilization Management & Review Specialist will conduct effective evaluations of client UM/UR processes in a way that streamlines operational processes in services engagements and enhances client satisfaction in consultative roles. Utilization Management & Review Specialist will be tasked with provider education and will be a key point of contact within the management of inventory touching on UM/UR processes, including denials prevention, clinical appeal, and operational auditing. This position is also involved in the development and streamlining of Department workflows, job aides, and developing/delivering presentations to management and client contemporaries.

Duties and Responsibilities

• Serve as point of contact for client operational staff members impacted by UM/UR Processes
• Track and monitor solutions implemented for clients and operational staff 
• Identifies system needs to support short and long term product strategy.
• Establishes product development policies to guide product development.
• Project manage quality audits, chart audits, and reviews of medical records as needed for either complex high-cost cases or cases with quality of care concerns
• Investigates and documents PQIs and works with the Director to appropriately close and track cases 
• Manage the quality oversight process.
• Review and monitor the monthly Utilization Management (UM) data reports to identify performance
• Determine patterns of non-compliance with obtaining prior authorizations and recommend corrective action plans for non-compliant providers. 
• Coordinate with the Director of Denials Strategy & Process in achieving continued process improvement of overall operations to increase efficiency, accuracy, automation and best-practice reporting.
• Collaborate on the enhancements and updates to internal processes, programs, policies/procedures and process flows. 
• Evaluate current data reporting, and work with the Director and Strategy & Process team to develop actionable reporting.
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

Qualifications

• Active, RN license required
• At least 5 years’ experience working in a managed care environment
• At least 5 years’ experience managing programs to maintain State and Federal compliance programs.
• Experience with maintaining compliance with the Department of Managed Care (DMHC) and the Department of Insurance (DOI).
• Knowledge of Healthcare Effective Data and Information Set (HEDIS), Quality Assurance Reporting Requirements (QARR), National Committee for Quality Assurance (NCQA) and related, preferred.
• Working knowledge of MCG (Milliman) and the ability to accurately apply guidelines to clinical evidence.
• A working knowledge of Quality Improvement, UM and Care Management (CM) industry targets, benchmarks and best practice.
• Experience in a management position, preferred
• Ability to interpret data reports and implement action plans based on the findings
• Proficient in the use of Microsoft Office Suite, Highly skilled at using the Internet 
• Ability to prepare documents, reports, spreadsheets and analyses independently. Must learn and teach effectively with all types of training, including online. 
• Strong interpersonal skills, ability to communicate and manage well at all levels of the organization and with staff at remote locations essential
• Ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results-orientation
• Excellent written and verbal communication skills required
• Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others
• Gracious and welcoming personality for customer service interaction

Working Conditions

• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.