Job Summary:

The Utilization Management (UM) Operations Strategy & Implementation Lead is responsible for maintenance and oversight of all operational and compliance activities that support the UM department. This role will also drive key process changes and identify key gaps and variances across the department.

Essential Functions:

• Utilize process controls to achieve operational excellence in all areas within the department
• Actively work with UM leadership in closing variances of identified risks to compliance
• Utilize process improvement frameworks to drive continuous improvement
• Assess data to identify any misalignment with compliance, regulatory and operational requirements and support process changes that result from any identified opportunities
• Collaborate with analytics, Physical Health and Behavioral Health clinical teams, compliance and regulatory to ensure regulatory content is represented in the data sets and validated
• Assist in implementations of changes through systematic and measurable actions ensuring regulatory, accreditation, and compliance business goals are met
• Assist in the creation of the UM (including Clinical responses) for the NQTL data and narrative submissions
• Proactively build and manage various relationships to improve standardization and interdepartmental collaboration on enterprise goals and initiatives
• Provide Clinical and UM support on parity associated internal compliance workgroups
• Work collaboratively with the appropriate departments to define and utilize outcome measurements, and support a culture of compliance
• Partner as needed with other departments to support in the implementation of process improvement opportunities, new business rules, new products and delegations
• Support change management initiatives that impact the department
• Assist in analysis and recommendations for annual product filings and UM strategy from a parity perspective
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree in healthcare, population health or related field, or equivalent years of relevant work experience is required
• A minimum of five (5) years of experience in UM or related to the responsibilities of this position is required
• Previous experience with quality control and/or process standards is preferred

Competencies, Knowledge and Skills:

• SME in federal/state laws and regulations
• Proficient use of Microsoft Office Suite, to include Word, Excel, PowerPoint, Outlook, and Visio with a strong willingness to learn
• Ability to analyze processes across multiple functional areas
• Ability to work independently and within a team environment
• Understanding of ROI and risk avoidance
• Demonstrated change management and continuous improvement leadership knowledge
• Ability to gather data and create meaningful analysis
• Ability to review and implement evidence-based trends
• Strong oral, written and interpersonal communication skills
• Strong understanding NCQA and/or CMS, accreditation and audit standards with knowledge of regulatory reporting, and compliance requirements
• Strong attention to detail and time management skills
• Effective problem-solving skills with attention to detail
• Effective listening and critical thinking skills

Licensure and Certification:

• Current, unrestricted Registered Nurse (RN) licensure is preferred
• Six Sigma or project management certifications are preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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