Specialist, Utilization Management

Transcarent

7h

About The Position

The Specialist, Utilization Management provides operational support and subject matter expertise to ensure the effectiveness and continuous improvement of Accolade's Utilization Management program. This role supports program execution by monitoring vendor process requirements, managing day-to-day program operations while identifying opportunities for process optimization and facilitating cross-functional collaboration to meet operational deliverables and business objectives. The Specialist, Utilization Management builds strong working relationships across Provider Services, external vendor partners (including AHH), and internal clinical and service operations teams to ensure seamless program integration and execution. This function is critical to Accolade’s ability to create and maintain trust in the quality of our services and dedication to continuous improvement with our customers and their consultant partners.

Requirements

• Bachelors’ Degree or an equivalent combination of education/experience.
• 2+ years of relevant experience in utilization management operations, prior authorization coordination, UM program support, or healthcare operations.
• Working knowledge of utilization management principles, prior authorization processes, and medical necessity review workflows
• Excellent analytical, problem solving, communication, presentation and conflict resolution skills.
• Strong research and analytical skills with ability to synthesize complex information and identify trends.
• Demonstrated ability to work independently, produce high quality deliverables and identify project delivery risks.
• Ability to work in an environment with changing priorities and embrace change.
• Continuous process improvement mindset.
• Experience interacting with external stakeholders.
• Proficiency in SmartSheets, Microsoft Word/Excel and PowerPoint.

Nice To Haves

• Experience working with external vendors, health plans, or third-party administrators in a UM or provider services capacity preferred

Responsibilities

• Support the evolution of Accolade’s UM program by identifying improvement opportunities.
• Monitor vendor performance against contractual SLAs, escalating gaps and collaborating on corrective action plans to ensure prior authorization/pre-certification delivery meets operational goals.
• Ensure adherence to UM policies and procedures across internal teams and vendor partners through training support, process monitoring, and issue resolution.
• Research and support resolution of client, member, and provider escalations related to UM determinations and processes, coordinating across internal teams and vendor partners to ensure timely, compliant, and member-focused outcomes.
• Facilitate issue resolution with health plan partners, vendors, and provider services team, ensuring timely response to operational complexities and client/member/provider or ecosystem partner inquiries.
• Serve as a key liaison between Accolade operations and AHH, managing day-to-day communication, escalations, and workflow coordination.
• Collaborate with cross-functional teams to support implementation of new processes and system enhancements.
• Partner with implementation team as a UM subject matter expert during new customer onboarding, providing guidance on program setup, criteria configuration, and workflow design.
• PES_Utilization Management Sharepoint folder/file structure, manage permissions and support colleagues in navigating the repository. Identify and implement continouous improvements, as applicable.
• Support internal and vendor related audit planning and preparation meetings including: Audit Kick-Off, Status Meetings, Call Finalization Meetings, Mock Audit, Audit Day and Post-Audit Follow-Up.

Benefits

• Competitive medical, dental, and vision coverage
• Competitive 401(k) Plan with a generous company match
• Flexible Time Off/Paid Time Off, 13 paid holidays
• Protection Plans including Life Insurance, Disability Insurance, and Supplemental Insurance
• Mental Health and Wellness benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level