Note: The job is a remote job and is open to candidates in USA. Capital Blue Cross is a health insurance company focused on improving the health and well-being of its members and communities. The Implementation Consultant Utilization Management role supports strategic initiatives, operational improvements, regulatory compliance, data analysis, and cross-functional implementation efforts to optimize utilization management programs and medical cost outcomes.

Responsibilities

• Partner with UM leadership and cross-functional teams to execute strategic initiatives that enhance utilization management programs, workflows, and outcomes
• Support the planning, coordination, and execution of UM initiatives, including program enhancements, scope expansions, and operational improvements
• Assist in evaluating financial, quality, and operational impacts of UM programs and proposed changes
• Manage multiple concurrent projects, ensuring timelines, deliverables, and dependencies are effectively coordinated
• Prepare and present relevant items for committee review as it relates to UM projects and initiatives (i.e., IUMC, MAUMC, AIGC)
• Perform monthly maintenance of the Single Source Preauthorization List. Accurately update the Single Source Preauthorization list and provide oversight of web publications to ensure information is accurately conveyed
• Monitor and analyze relevant data following a change in preauthorization management of procedure code(s). Investigate root causes of significant data changes. Identify opportunities for process improvement or refinement. Compile review findings and provide a comprehensive summary report to UM leadership
• Stay current on industry trends, regulatory updates, and best practices related to utilization management
• Contribute to a culture of continuous improvement, collaboration, and accountability within UM
• Perform ongoing analysis and periodic audits of vendor’s current systems in use including their effectiveness, usability and functionality and make recommendations for system and/or process improvements
• Monitors and reports on Capital and delegated UM vendor project progress by tracking activity; resolving problems; publishing progress reports; recommending actions. Troubleshoots issues; responsibility for detecting potential issues and implementing solutions
• Develop project plans and strategies in line with assigned initiatives
• Collects and analyzes data on utilization, outcomes, safety, and costs to determine trends and identify problem areas. Lead clinical requirements; creation and review process
• Identifies priority development and process improvement needs. Including defining use case and business need. Prioritizes project tasks, manages timelines, maintain project plans
• Monitors utilization trends and medical cost to identify strategies for addressing trends/cost. Presents strategies for review/consideration
• Perform other duties as assigned

Skills

• Proficient with Microsoft Office, MS SharePoint, Excel, and Visio
• Work experience in project management
• Effective interpersonal and active listening skills
• Effective written/verbal communication, physician relations and customer satisfaction skills
• Ability to multi-task and prioritize
• Time management skills
• Process Improvement skills
• Adaptability with change management skills
• Knowledge of CMS and NCQA standards for Utilization Management for health plan compliance
• Knowledge of current and emerging clinical practice guidelines
• 5+ years' experience in the health insurance, or other related healthcare field
• Experience in healthcare implementation
• Demonstrated excellent public speaking and written communication skills
• Minimum active LPN licensure required
• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds
• 5 + years' experience in developing and delivering training, preferably in a health related business

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Retirement Plan
• Paid Time Off
• Holidays
• Volunteer time off
• Incentive Plan
• Tuition Reimbursement
• Remote work
• Flexible work environment
• Support for health and wellbeing
• Encouragement to volunteer in the community
• Training and continuing education
• Professional and personal growth support

Company Overview