Utilization Management Manager

KPI Tracking and Reporting:

Assist in the collection, organization, and analysis of utilization management KPIs for reporting to senior leadership and payers.

Generate regular reports and dashboards in collaboration with the Data Analytics team.

Utilization Analysis:

Conduct analyses of concurrent and retrospective claims to identify primary utilization drivers by provider, physician, and service.

Contribute insights into utilization trends and cost drivers using data visualization tools.

Segment and Payer-Level Data Review:

Perform data reviews on utilization patterns across business segments and payers to support targeted performance improvements.

Provide input on payer-specific utilization trends to aid in developing remediation plans.

Large Policy Support:

Contribute to large policy utilization management by analyzing data on outlier claims and high-risk members.

Assist in identifying potential interventions or consultations needed with payers.

Education: Bachelor’s degree in healthcare management, statistics, or a related field.

1. Data Analysis and Interpretation

• Analytical Proficiency: Ability to analyze concurrent and retrospective claims data to identify utilization trends, drivers, and cost-saving opportunities.
• Data Interpretation: Skilled in drawing meaningful insights from complex data sets, understanding the implications of utilization patterns, and translating findings into actionable recommendations.

2. KPI Monitoring and Reporting

• Performance Metrics Management: Proficient in establishing, monitoring, and reporting on utilization management KPIs, ensuring that performance aligns with organizational and payer expectations.
• Regular Reporting: Ability to create clear and comprehensive reports for senior leadership and payers, showcasing trends, areas of concern, and improvements.

3. Technical Proficiency in Data Tools

• Data Visualization Tools: Skilled in using tools like Tableau, Power BI, or similar platforms to create dashboards and visual reports that aid in communicating data insights.
• Data Analytics Software: Experience with analytics software (e.g., Excel, SQL, R, or Python) to manipulate data, run queries, and perform statistical analysis on utilization patterns.

4. Healthcare and Utilization Management Knowledge

• Understanding of Healthcare Utilization: Strong knowledge of utilization management processes, including criteria for medical necessity, cost management, and utilization trends.
• Medical Coding Knowledge: Familiarity with ICD-10, CPT, and other medical coding standards, which is essential for accurate data analysis and claims interpretation.

5. Problem-Solving and Root Cause Analysis

• Strategic Problem-Solving: Ability to identify root causes behind high-utilization drivers and work with internal teams to recommend remedial actions.
• Detail-Oriented: Precision in examining claims and utilization data to identify specific patterns, anomalies, or drivers that require action.

6. Communication and Reporting Skills

• Clear Communication: Skilled in presenting complex data and insights to a diverse audience, including both clinical and non-clinical stakeholders.
• Collaborative Reporting: Works closely with cross-functional teams (e.g., Data Analytics, Claims Review) to ensure alignment on data interpretation and recommended actions.

7. Stakeholder Engagement

• Payer and Provider Relations: Ability to engage with external payers and internal teams to discuss findings and collaborate on protocol changes that manage utilization and costs effectively.
• Cross-Functional Collaboration: Capable of working across departments to ensure that data insights inform broader business decisions and strategic initiatives.

8. Continuous Improvement Focus

• Process Optimization: Committed to refining utilization management and reporting processes to improve accuracy, efficiency, and cost-effectiveness.
• Adaptability: Able to quickly adjust analysis and reporting approaches based on evolving business needs, new data patterns, or regulatory requirements.

Experience: 5+ years of experience in data analysis, healthcare claims, or utilization management.

Job Type: Full-time