The Clinical Utilization Management (UM) Specialist is responsible for developing, implementing, and maintaining efficient UM operational processes within the UM team, ensuring timely and accurate action,  regulatory compliance, and providing support as the program scales. This is an individual contributor role.

Responsibilities:

• Operational Support to the Clinical UM team:
• Document, and implement efficient Clinical UM operational workflows and procedures, 
• Provide operational support for the UM program, addressing inquiries and resolving issues in a timely manner. This includes daily monitoring of and taking required action on incoming/outging reporting from UM vendor(s), client queries and updates, attending client and vendor meetings and resolving action items, and supporting the UM program manager in daily standard work.
• Support the scaling of the Clinical UM program by assisting with the implementation of new processes, technologies, and workflows.
• Collaborate with cross-functional teams to ensure integration of UM operations with other departments, including Claims, Product,  Engineering, Care Navigation.

Prior Authorization List and Logic Build and Maintenance.

• Responsible for Utilization Management configuration - which includes the clinical interpretation of UM needs and translation of those needs into prior authorization requirements.
• Build and Maintain accurate PA lists across clients, internal teams, and provider/member-facing sites. Ensure that updates are reflected consistently across all impacted areas.
• Own and maintain standard and custom prior authorization logic/rules for reliable application of prior authorization requirements.
• Ensure timely communication of changes to UM vendor, claims, and provider-servicing teams.
• Support Claims UM Operations Manager with implementation of PA list changes and adjudication rules for all clients, to ensure accurate application of prior authorization requirements, and timely resolution of any related issues.

Client and Vendor Support

• Attend meetings with UM Vendor(s), clients, and internal CH teams to support new client implementations and ongoing program maintenance
• Documentation and Reporting:
• Maintain accurate and up-to-date documentation of Clinical UM processes, procedures, and workflows.

Qualifications:

• Bachelor's degree in healthcare administration, or a related field
• Minimum of 3-5 years of experience in UM support or a related healthcare role, within a health plan, Managed Care Organization (MCO), or TPA setting
• Strong understanding of UM principles, processes, and regulations.
• Excellent analytical, problem-solving, and organizational skills.
• Strong written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Experience with healthcare technology platforms and data analysis tools.

Pay Transparency Statement 

This is a hybrid position based out of one of our offices: Plano, TX, or Lehi, UT. Hybrid employees are expected to be in the office two days per week.#LI-hybrid 

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.