Clinical Utilization Management & Analytics Specialist

Teacher Retirement System of Texas (TRS)•Austin, TX

37d•$108,036 - $150,000•Onsite

About The Position

The Clinical Utilization Management and Analytics Specialist performs senior-level clinical and analytic work to improve the value of TRS health programs. The position may be filled by a registered nurse, physician, or pharmacist with substantial healthcare analytics and utilization management experience. Using data from utilization management outcomes, prior authorization, provider quality, and claims, the position identifies avoidable or low-value spending and develops clinically appropriate opportunities to improve efficiency and quality of healthcare delivery. The position oversees the health plan administrator’s utilization management operations and works with internal stakeholders, consulting firms, and benefit vendors to reduce waste while protecting quality, safety, timely access, and medically necessary care. The role monitors and improves utilization management operations; designs and evaluates clinical requirements, protocols, and programs; analyzes utilization, claims, outcomes, and provider data; and develops recommendations, reports, dashboards, and business cases. It also provides clinical expertise for contract oversight, vendor management, audits, procurements, policy development, and special projects.

Requirements

Bachelor’s degree in nursing, medicine, pharmacy, healthcare administration, health informatics, data analytics, public health, or a closely related field; or a professional degree required by licensure.
Five years of progressively responsible experience in clinical practice, provider or health plan utilization management, or healthcare analytics.
Two years of experience in utilization management, prior authorization, healthcare quality, provider operations, health plan operations, or related clinical review activities, including provider-health plan coordination.
Experience reviewing medical records and applying clinical criteria to healthcare services.
Current unrestricted professional license appropriate to the candidate’s clinical discipline, such as RN, physician (MD or DO), or pharmacist (RPh or PharmD), issued or recognized by Texas, as applicable.
Knowledge of utilization management program design, operations, and industry standards; health plan administration and managed care operations; evidence-based clinical guidelines and utilization management methodologies; healthcare quality improvement and population health principles; health insurance benefit administration and provider reimbursement concepts; and applicable federal and state healthcare regulations and accreditation standards.
Skill in vendor performance management and contract oversight; clinical program evaluation and implementation; advanced analysis of utilization, prior authorization, claims, provider, site-of-care, outcomes, and population health data; strategic problem solving and decision making; stakeholder engagement and relationship management; and technical writing, reporting, and presentation development.
Ability to evaluate complex clinical and operational programs; translate clinical concepts into business and policy recommendations; influence outcomes through collaboration with vendors and stakeholders; analyze authorization patterns, provider variation, site of care, utilization, cost, quality, and outcomes to identify improvement opportunities; and manage multiple projects and priorities simultaneously.

Nice To Haves

Certification in Utilization Management (CPUM), Case Management (CCM), Healthcare Quality (CPHQ), or a related specialty.
Experience working with a health plan, managed care organization, third-party administrator, Medicare program, Medicaid program, pharmacy benefit manager, or governmental healthcare program.
Experience supporting healthcare vendor oversight, audits, or compliance activities.
Demonstrated experience using analytic tools to analyze and visualize utilization, prior authorization, claims, provider, site-of-care, or outcomes data and communicate actionable findings.
Knowledge of public sector health benefit programs.

Responsibilities

Monitor and improve the health plan administrator’s utilization management operations, including prior authorization, concurrent and retrospective review, case management, appeals, and transitions of care.
Design custom utilization management requirements, clinical protocols, and performance expectations, and assess adherence to established criteria and industry standards.
Evaluate vendor performance and recommend actions to reduce waste, improve affordability and outcomes, and preserve access to medically necessary care.
Serve as a primary clinical and analytic resource for utilization management contract oversight, including prior authorization, medical necessity criteria, peer-to-peer review, site-of-care optimization, exception management, and escalated clinical issues.
Collaborate with TRS leadership, consultants, and health plan administrators to design and implement custom utilization management requirements and clinical programs.
Work with health plan administrators to operationalize approved utilization management changes and ensure consistent implementation.
Evaluate proposed utilization management policies, clinical criteria, and program enhancements for alignment with TRS objectives.
Develop evidence-based initiatives that reduce unnecessary high-cost care and promote appropriate lower-cost settings and less-invasive, high-quality alternatives.
Assist with developing contract requirements, performance standards, and clinical program specifications during procurements and contract amendments.
Coordinate implementation activities related to new utilization management initiatives, clinical programs, and regulatory changes.
Analyze utilization management, prior authorization, site-of-care, claims, outcomes, and provider data to identify cost drivers, avoidable utilization, low-value care, variation, clinically appropriate alternatives, and opportunities to improve quality and total cost of care.
Evaluate proposed programs for effects on quality, access, site-of-care, member experience, and total cost.
Develop reports, dashboards, business cases, and recommendations that quantify opportunities and measure cost, utilization, quality, and outcomes.
Provide clinical expertise for policy development, vendor management activities, audits, procurements, and special projects.
Perform related work as assigned.