Note: The job is a remote job and is open to candidates in USA. AmeriHealth Caritas is a mission-driven health care organization that delivers comprehensive, outcomes-driven care and health care solutions. The Utilization Management Admin & Operations Program Specialist coordinates and monitors utilization management program objectives, supports quality improvement initiatives, develops policies and processes, validates reports, and represents UM at quality committees.
Responsibilities
- Responsible for supporting successful development and evaluation of an annual UM work plan and program description by collaborating with corporate and market UM leadership and other areas throughout the organization as necessary
- Requests reports both standing and ad-hoc, supports validation of the data upon report completion, Identifies, resolves and/or escalates problematic UM areas to UM leadership, that may impact the department’s ability to achieve annual goals
- Participates in the development, implementation and maintenance of UM policies and procedures
- Works professionally and efficiently with all functional areas in meeting organizational and departmental UM goals
- Collaborates with each Market to ensure policies are created and /or updated in accordance with State, Federal, regulatory and accrediting body’s standard requirements
- Ensures timely submission of policy updates, report, and program documents to appropriate committee for approval
- Participates on Quality Committees to present reports, policies and/ or program documents that are consistent in meeting regulatory and accrediting body requirements
- Initiates review and submission process for state approval of program documents when state approval is required
- Maintains tracking and version control for all policies and standard operating procedures
- Participates in New Business Implementation process as assigned to assist with development of program documents, policies, workflows
- Serves as a resource for utilization management teams during new business go-live
Skills
- Associate's Degree or equivalent work experience required
- Minimum of 3 years in clinical or service quality improvement required
- Minimum of 3 years in healthcare delivery required
- Experience with medical management systems, CMS interoperability, Electronic Health Records exp such as Epic, Cerner, Jiva
- Excellent organizational, analytical and interpersonal skills
- Excellent written and verbal communication skills
- Ability to work successfully within all levels of the organization
- Ability to design, develop and implement projects to address financial, quality and service improvements
- Proficient PC skills in a Windows based environment
- Ability to read contracts or legal documents and extract key language to support program and policy development
- Bachelor's Degree preferred
- Managed health care experience preferred
- Successful management of NCQA accreditation survey preferred
Benefits
- Flexible work solutions including remote options and hybrid work schedules
- Paid time off including holidays and volunteer events
- Health insurance coverage for you and your dependents on Day 1
- 401(k)
- Tuition reimbursement
- Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Company Overview
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