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The Utilization Management (UM) Operations Specialist plays a critical role in the successful operationalization and ongoing support of Collective Health's UM program. This position is responsible for developing, implementing, and maintaining efficient UM operational processes, ensuring regulatory compliance, and providing vital support as the program scales. This is an individual contributor role focused on execution and optimization.

What you'll do:

• Operational Implementation and Support
  • Develop, document, and implement efficient UM operational workflows and procedures,
  • Provide operational support for the UM program, addressing inquiries and resolving issues in a timely manner. This includes daily monitoring of and taking required action on incoming/outging reporting from UM vendor(s)
  • Support the scaling of the UM program by assisting with the implementation of new processes, technologies, and workflows.
  • Collaborate with cross-functional teams to ensure seamless integration of UM operations with other departments, including Claims, Product, Engineering, Care Navigation.
• Prior Authorization List and Logic Build and Maintenance
  • Build and Maintain accurate PA lists across all clients, internal teams, and provider/member-facing sites
  • Ensure timely communication of changes to UM vendor and claims team
  • Own and build standard and custom prior authorization logic/rules for reliable application of prior authorization requirements.
  • Support Claims UM Operations Manager with implementation of PA list changes and adjudication rules for all clients, to ensure accurate application of prior authorization requirement, and timely resolution of any related issues.
  • Change management: Manage intake, documentation, and roll-out of client, vendor, or CH-initiated prior authorization changes.
• Client and Vendor Support
  • Attend meetings with UM Vendor(s), clients, and internal CH teams to support new client implementations and ongoing program maintenance
• Process Improvement
  • Continuously evaluate and identify opportunities to improve UM processes and workflows, including vendor related workflows
  • Implement process changes to enhance efficiency, effectiveness, and quality of UM services.
  • Utilize data and analytics to support process improvement initiatives.
• Documentation and Reporting
  • Maintain accurate and up-to-date documentation of UM processes, procedures, and workflows.
  • Develop and generate reports on UM performance metrics and operational activities.

To be successful in this role, you'll need:

• Bachelor's degree in nursing, healthcare administration or healthcare-related field.
• Minimum of 3-5 years of experience in UM operations or a related healthcare operations role, within a health plan, Managed Care Organization (MCO), or TPA setting
• Strong understanding of UM principles, processes, and regulations.
• Excellent analytical, problem-solving, and organizational skills.
• Strong written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Experience with healthcare technology platforms and data analysis tools.
• Proficiency in analyzing complex clinical documentation and data trends.

Pay Transparency Statement

This is a hybrid position based out of one of our offices: Plano, TX, or Lehi, UT. Hybrid employees are expected to be in the office two days per week.#LI-hybrid

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.