Utilization Management SME (Compact or PA Licensed)

Position Responsibilities

• Specific Design utilization management programs, processes and workflows to meet operational goals and anticipate future strategic needs
• Evaluate ability to automate and streamline standard work
• Analyze and monitor quality, cost reimbursement and utilization trends
• Develop and oversee inpatient and outpatient utilization management programs to ensure: cost-effective use of patient care resources, case delivery at the most appropriate level, collaboration with the medical staff on resource utilization issues and compliance with utilization-related private contracts, all regulating agencies, and applicable federal and state regulatory mandates
• General Provide direction for health plan market/ product level operational oversight, management and performance improvement
• Leverage industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services
• Deliver innovative, integrated solutions in support of client goals and engagements
• Support or lead engagements ensuring completion of contracted services: create and/ or manage to project plans, write proposals/reports, present to Client executives, and facilitate, advise and persuade key decision makers and influencers
• Deliver concise, clear interpersonal communication to both internal and external audiences
• Facilitate streamlined exchange of information with all levels of Clearlink and client organization(s)
• Articulate performance across multiple projects with qualitative and quantitative results/ outcomes
• Influence others to understand and accept strategies, goals and plans in response to changing business conditions
• Develop methodologies and best practices to be applied across individual account strategies/ client plans
• Establish goals and track progress to ensure achievement
• Adept in adapting processes, approach, plan and/ or activities in real time when targets, goals or timelines are at risk to ensure critical path activities are achieved
• Support account management relationships with key client decision makers
• Develop and deploy management reporting, if indicated, to support monitoring and improvement of performance, implementing plans for improvement as necessary
• Responsible for the engagement quality, maintaining appropriate resources, competency training and education of staff
• Responsible for approving and managing day to day engagement resourcing/ time and attendance as an Engagement Manager
• Oversee compliance with internal client related audits, support Client preparation for external audits and surveys

Position Qualifications

• Proficiency managing complex work in challenging environments through the alignment of resources and prioritization of efforts to ensure on time, in scope project and/ or strategic delivery
• Managed care industry expertise in trends, innovation, operations, financing, costs, requirements, performance and outcomes
• New product/ market design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid or associated lines of business
• New population identification, program design and implementation to support needs/ requirements of increasingly complex memberships while ensuring stable operations and target outcomes
• Strong understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures
• Work closely with concepts such as HIPAA, as well as State’s Department of Insurance, Federal and State Health and Human Services, CMS, NCQA, and URAC, to ensure compliance with complex regulatory structures
• Strategic thinker with ability to produce and manage system-wide change through influence and persuasion
• Knowledge of project management principles, methods, and techniques
• Ability to organize, prioritize, and manage multiple complex projects
• Excellent communication skills both written and oral
• High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred
• Current unencumbered Compact or Pennsylvania RN license
• Bachelor’s Degree in Healthcare Administration or related field, Master’s degree preferred
• 5+ years progressive leadership experience in health plan operations and utilization management delivering results and managing teams and projects in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities
• 3+ years of management experience in a government payor environment at a Director or equivalent level with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, etc)