UM Operations Strategy Implementation Lead

Job Summary:

The Utilization Management (UM) Operations Strategy & Implementation Lead is responsible for maintenance and oversight of all operational and compliance activities that support the UM department. This role will also drive key process changes and identify key gaps and variances across the department.

Essential Functions:

Utilize process controls to achieve operational excellence in all areas within the department

Actively work with UM leadership in closing variances of identified risks to compliance

Utilize process improvement frameworks to drive continuous improvement

Assess data to identify any misalignment with compliance, regulatory and operational requirements and support process changes that result from any identified opportunities

Collaborate with analytics, Physical Health and Behavioral Health clinical teams, compliance and regulatory to ensure regulatory content is represented in the data sets and validated

Assist in implementations of changes through systematic and measurable actions ensuring regulatory, accreditation, and compliance business goals are met

Assist in the creation of the UM (including Clinical responses) for the NQTL data and narrative submissions

Proactively build and manage various relationships to improve standardization and interdepartmental collaboration on enterprise goals and initiatives

Provide Clinical and UM support on parity associated internal compliance workgroups

Work collaboratively with the appropriate departments to define and utilize outcome measurements, and support a culture of compliance

Partner as needed with other departments to support in the implementation of process improvement opportunities, new business rules, new products and delegations

Support change management initiatives that impact the department

Assist in analysis and recommendations for annual product filings and UM strategy from a parity perspective

Perform any other job duties as requested

Education and Experience:

Bachelor’s degree in healthcare, population health or related field, or equivalent years of relevant work experience is required

A minimum of five (5) years of experience in UM or related to the responsibilities of this position is required

Previous experience with quality control and/or process standards is preferred

Competencies, Knowledge and Skills:

SME in federal/state laws and regulations

Proficient use of Microsoft Office Suite, to include Word, Excel, PowerPoint, Outlook, and Visio with a strong willingness to learn

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 NCQA and/or CMS, accreditation and audit standards with knowledge of regulatory reporting, and compliance requirements

Strong attention to detail and time management skills

Effective problem-solving skills with attention to detail

Effective listening and critical thinking skills

Licensure and Certification:

Current, unrestricted Registered Nurse (RN) licensure is preferred

Six Sigma or project management certifications are preferred

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

$83,000.00 - $132,800.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Salary

Organization Level Competencies

- Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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