Sr. Manager, Medical Informatics - Utilization Management Analytics
About The Position
The Healthcare Quality Affordability (HQA) Analytics team plays a key role in discovering information hidden in vast amounts of data that can lead to smarter decisions and deliver better service for our customers and contain the rising cost of healthcare. The Sr. Manager, Medical Informatics - Utilization Management (UM) Analytics will report to the Director of HQA Analytics and lead a team responsible for Prior Authorization, Concurrent Review, and broader UM analytics. This leader will translate clinical and operational priorities into actionable analytical strategies, strengthen organizational understanding of utilization and authorization performance, develop team capabilities, and deliver insights that inform operational improvement, executive decision-making, affordability, quality, and member outcomes across lines of business. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Requirements
- Requires a Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree.
- A Graduate degree (MPH, MBA, MS, MA, RN, or RHIA) in a relevant field and 2 years of post-degree healthcare analytics experience is preferred
- Requires 8 years of prior relevant experience in a medical informatics position within the healthcare industry
- Requires 4 years of prior people management experience with direct responsibility for supervising, coaching, and evaluating direct reports
- Command of legal and regulatory issues that apply to data exchange, processing, and analysis in the California health insurance industry
- Demonstrated understanding of key UM concepts and performance measures, including authorization volume, approval and denial rates, decision timeliness, inpatient admissions, length of stay, avoidable days, levels of care, readmissions, and authorization-to-claims reconciliation
- Strong knowledge of healthcare payer operations, with direct analytical experience supporting UM, Prior Authorization, Concurrent Review, or related clinical functions is strongly preferred
- Four (4) years of experience analyzing California payer/provider data and interpreting utilization, cost, and outcomes measures is preferred
- Two (2) years of experience applying HIPAA and California health data privacy requirements to data exchange, processing, and analysis is preferred
Responsibilities
- Lead, develop, and mentor a team of analysts supporting Prior Authorization, Concurrent Review, and broader UM analytics
- Define and execute the UM analytics strategy and roadmap in alignment with organizational, clinical, regulatory, and affordability priorities
- Serve as the primary analytics partner to Prior Authorization, Concurrent Review, and Medical Management leadership, translating business needs into actionable analytical strategies
- Oversee analytics related to authorization volume, approval and denial rates, decision timeliness, inpatient utilization, length of stay, avoidable days, readmissions, and other key UM performance indicators
- Evaluate the impact of UM programs, clinical policies, prior authorization requirements, and operational interventions on utilization, cost, quality, and member and provider experience
- Direct complex analyses integrating authorization, clinical, membership, provider, claims, and financial data to identify performance gaps, emerging risks, and improvement opportunities
- Partner with Medical Management, Network Management, Claims, Pharmacy, Appeals and Grievances, Compliance, Finance, Product, Technology, and data teams to deliver comprehensive insights and recommendations
- Oversee the development of dashboards, recurring reporting, self-service tools, and executive performance summaries using Tableau, Power BI, and other analytical platforms
- Establish consistent definitions, methodologies, governance, documentation, and quality-control standards for UM reporting and analytics
- Present findings and recommendations to senior leadership and monitor resulting actions to ensure analytics translate into measurable operational improvements
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What This Job Offers
Job Type
Full-time
Career Level
Manager
