Utilization Management Admin & Operations Program Specialist

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement. Your career starts now. We are looking for the next generation of health care leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. Role Overview As part of the Utilization Management (UM) Administrative Team, the UM Administrative and Operations Program Specialist is responsible for the coordination and ongoing monitoring of UM program objectives, including support of performance improvement projects for service and clinical activities, integrating the quality improvement and efficiencies into all UM department activities. This role implements and supports the overall implementation of UM programs that meet or exceed applicable State, Federal and NCQA standards. Under the direction of UM Leadership, you will support new and existing business through policy writing and updates, development of program documents and updates, development of processes, report development and validation of reports prior to submission. This position also represents UM at Quality meetings to present changes, documents and work-plan required items. Work Arrangement Remote roleMonday through Friday from 8:30 AM EST to 5:00 PM EST 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 necessaryRequests 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 goalsParticipates in the development, implementation and maintenance of UM policies and proceduresWorks professionally and efficiently with all functional areas in meeting organizational and departmental UM goalsCollaborates with each Market to ensure policies are created and /or updated in accordance with State, Federal, regulatory and accrediting body’s standard requirementsEnsures timely submission of policy updates, report, and program documents to appropriate committee for approvalParticipates 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 requiredMaintains tracking and version control for all policies and standard operating proceduresParticipates in New Business Implementation process as assigned to assist with development of program documents, policies, workflowsServes as a resource for utilization management teams during new business go-live Education And Experience Associate’s Degree or equivalent work experience requiredBachelor’s Degree preferredMinimum of 3 years in clinical or service quality improvement requiredMinimum of 3 years in healthcare delivery requiredManaged health care experience preferredSuccessful management of NCQA accreditation survey preferredExperience with medical management systems, CMS interoperability, Electronic Health Records exp such as Epic, Cerner, Jiva Skills Excellent organizational, analytical and interpersonal skillsExcellent written and verbal communication skillsAbility to work successfully within all levels of the organizationAbility to design, develop and implement projects to address financial, quality and service improvementsProficient PC skills in a Windows based environmentAbility to read contracts or legal documents and extract key language to support program and policy development Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.