UM Operations Strategy Implementation Lead

CareSource•Dayton, OH

4d•$83,000 - $132,800

About The Position

The Utilization Management (UM) Operations Strategy & Implementation Lead maintains and oversees operational and compliance activities that support the UM department. The role drives process changes and identifies gaps and variances across the department. It works with UM leadership and cross-functional partners to address compliance risks, improve processes, validate regulatory data, implement changes, and support enterprise goals and initiatives. The position also supports UM parity work, including NQTL data and narrative submissions, internal compliance workgroups, and analysis and recommendations for annual product filings and UM strategy. It promotes standardization, measurable outcomes, and a culture of compliance.

Requirements

Bachelor’s degree in healthcare, population health, or a related field, or equivalent years of relevant work experience.
At least five years of experience in UM or in work related to the position’s responsibilities.
Subject matter expertise in federal and state laws and regulations.
Proficiency with Microsoft Office Suite, including Word, Excel, PowerPoint, Outlook, and Visio, and 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.
Knowledge of change management and continuous improvement leadership.
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 of NCQA and/or CMS accreditation and audit standards, 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.

Nice To Haves

Previous experience with quality control and/or process standards.
Current, unrestricted Registered Nurse (RN) licensure.
Six Sigma or project management certifications.

Responsibilities

Use process controls to achieve operational excellence across the department.
Work with UM leadership to close variances related to identified compliance risks.
Use process improvement frameworks to drive continuous improvement.
Assess data for misalignment with compliance, regulatory, and operational requirements and support resulting process changes.
Collaborate with analytics, Physical Health and Behavioral Health clinical teams, compliance, and regulatory partners to ensure regulatory content is represented in data sets and validated.
Assist with implementing changes through systematic and measurable actions that meet regulatory, accreditation, and compliance business goals.
Assist in creating UM submissions, including clinical responses, for NQTL data and narratives.
Build and manage relationships that improve standardization and interdepartmental collaboration on enterprise goals and initiatives.
Provide Clinical and UM support to parity-related internal compliance workgroups.
Work with appropriate departments to define and use outcome measurements and support a culture of compliance.
Partner with other departments as needed to implement process improvement opportunities, new business rules, new products, and delegations.
Support change management initiatives that affect the department.
Assist with analysis and recommendations for annual product filings and UM strategy from a parity perspective.
Perform other job duties as requested.