UM Operations Strategy Lead: Process Excellence

CareSource; United States; Remote; USD 83,000 - 133,000; Full time

Job summary

CareSource is seeking an Utilization Management Operations Strategy & Implementation Lead in the United States. The role oversees operational and regulatory activities for UM, driving key changes and addressing gaps to ensure compliance and performance.

You will collaborate with analytics, clinical teams, compliance, and regulatory to align data with requirements. Responsibilities include leading process controls, closing variances, and implementing improvements.

Qualifications

• Bachelor’s degree in healthcare, population health or related field, or equivalent years of relevant work experience is required
• A minimum of five (5) years of experience in UM or related to the responsibilities of this position is required
• Six Sigma or project management certifications are preferred

Responsibilities

• Utilize process controls to achieve operational excellence in all areas within the department
• Actively work with UM leadership in closing variances of identified risks to compliance
• Utilize process improvement frameworks to drive continuous improvement
• Assess data to identify any misalignment with compliance, regulatory and operational requirements and support process changes
• Collaborate with analytics, clinical teams, compliance and regulatory to ensure regulatory content is represented and validated
• Assist in implementations of changes through measurable actions ensuring regulatory goals are met
• Assist in the creation of the UM for NQTL data and narrative submissions
• Proactively build and manage relationships to improve standardization and collaboration
• Provide Clinical and UM support on parity internal compliance workgroups
• Work with departments to define and utilize outcome measurements
• Support implementation of process improvement opportunities, new business rules, and new products
• Support change management initiatives that impact the department
• Assist in analysis and recommendations for annual product filings and UM strategy
• Perform any other job duties as requested

Skills

Operational excellence

Regulatory compliance

Process improvement

Data analysis

Cross-functional collaboration

Change management

Communication skills

RN licensure (preferred)

Education

Bachelor’s degree in healthcare or related field

Tools

Microsoft Office Suite

Visio

Job description

CareSource is seeking an Utilization Management Operations Strategy & Implementation Lead in the United States. The role oversees operational and regulatory activities for UM, driving key changes and addressing gaps to ensure compliance and performance.

You will collaborate with analytics, clinical teams, compliance, and regulatory to align data with requirements. Responsibilities include leading process controls, closing variances, and implementing improvements.