Utilization Management Administrative and Operations Program Specialist

Title: Utilization Management Administrative & Operations Program Specialist

Location: United States

Job Description:

Primary Job Function Medical Management

ID 44475

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.

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 role
• Monday 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 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

   

Education and Experience

• Associate’s Degree or equivalent work experience required
• Bachelor’s Degree preferred
• Minimum of 3 years in clinical or service quality improvement required
• Minimum of 3 years in healthcare delivery required
• Managed health care experience preferred
• Successful management of NCQA accreditation survey preferred 

• Experience with medical management systems, CMS interoperability, Electronic Health Records exp such as Epic, Cerner, Jiva 

Skills

• 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

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.