Utilization Management Clinical Admin Operations Liaison

RPMGlobal; Northern (KY); Hybrid; USD 60,000 - 90,000; Full time

Benefits offered by this job

Remote options

Hybrid work schedules

Competitive pay

Paid time off including holidays

Health insurance on Day 1

401(k)

Tuition reimbursement

Job summary

AmeriHealth Caritas is seeking a UM Clinical Administrative Operations Liaison to coordinate and monitor utilization management programs, supporting performance improvement and QA activities. The role interacts with policy updates, reporting, and accreditation preparation to ensure regulatory compliance.

The ideal candidate holds a Bachelor’s degree with at least 3 years in clinical quality improvement and utilization management, and demonstrates strong analytical, organizational, and

Qualifications

• Bachelor's degree preferred with clinical or service quality improvement experience.
• Minimum 3 years in clinical or service quality improvement.
• Minimum 3 years in Utilization Management Review Process.

Responsibilities

• Support annual UM work plan and program descriptions with leadership.
• Request and validate reports; escalate issues impacting goals.
• Identify errors/risks in audit files and communicate them to UM leadership.
• Review accreditation standards; update documents and training materials.
• Develop and maintain UM policies and procedures; collaborate across functions.
• Assist with contract changes; support training for UM teams.

Skills

Organizational skills

Analytical skills

Interpersonal skills

Written communication

Verbal communication

PC skills

Contract reading

Education

Bachelor's Degree

Job description

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

As part of the Utilization Management (UM) Administrative team, the UM Clinical Administrative Operations Liaison is responsible for the coordination and ongoing monitoring of UM program objectives, including support of performance improvement projects for service and clinical activities, integrating the quality improvement and efficiencies into all UM department activities. Supports the UM Administrative and Operations Team activities using clinical knowledge to provide insight for processes, policies, and reporting. Supports the overall operation of UM programs that meet or exceed applicable State, Federal and NCQA standards Under the direction of the Manager UM Administrative Operations and Audit, supports UM through policy writing and updates, development of program documents and updates, development of processes, report development and validation of reports prior to submission. Provides support and clinical insight as needed for external audits and accreditation surveys. Represents UM at Quality meetings to present changes, documents and work-plan required items.

Responsibilities

• Responsible for supporting successful development and evaluation of an annual UM work plan and program description by collaborating with corporate and market UM leadership and other areas throughout the organization, as necessary.
• Request reports both standing and adhoc, supports validation of the data upon report completion, Identifies, resolves, and/or escalates problematic UM areas to UM leadership, which may impact the department’s ability to achieve annual goals.
• Using clinical knowledge and knowledge of UM review process to identify errors and risks with audit files, reporting and communicate any identified issues or risks to UM Admin and Ops manager and plan UM leadership.
• Works with the accreditation team to review accreditation standards to ensure Corporate UM documents are updated appropriately, training material developed/shared with team leaders, and communicated to the UM Admin team
• Participates in the development, implementation and maintenance of UM policies and procedures.
• Works professionally and efficiently with all functional areas in meeting organizational and departmental UM goals.
• Collaborates with each Market to ensure policies are created and /or updated in accordance with State, Federal, regulatory and accrediting body’s standard requirements.
• Ensures timely submission of policy updates, report, and program documents to appropriate committee for approval.
• Participates on Quality committees to present reports, policies and/ or program documents that are consistent in meeting regulatory and accrediting body requirements.
• Initiates review and submission process for state approval of program documents when state approval is required.
• Maintains tracking and version control for all policies and standard operating procedures.
• Participates in re-procurement and new business process as assigned to assist with development of program documents, policies, workflows
• Resource for UM teams regarding contract and /or regulatory changes.
• Supports training for UM admin and UM review teams as assigned.

Education/Experience

• Bachelor’s Degree preferred.
• Minimum of 3 years in clinical or service quality improvement required.
• Minimum of 3 years in Utilization Management Review Process required.

Other Skills:

• Managed Healthcare experience preferred.
• Successful management of NCQA accreditation survey preferred.
• Excellent organizational, analytical and interpersonal skills.
• Excellent written and verbal communication skills.
• Ability to work successfully within all levels of the organization.
• Ability to design, develop and implement projects to address financial, quality and service improvements.
• Proficient PC skills in a windows based environment.
• Ability to read Contracts or legal documents and extract key language to support program and policy development.

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.