Utilization Analyst

Overview

Summary:

The Utilization Analyst collaborates with the Chief Medical Officer (CMO) and Director of Contracting and Managed Care to track medical management, quality management, and patient and provider grievances, and assist in delivering superior customer service. This role focuses on implementing and managing effective utilization management processes that result in lower costs, efficient utilization of services, and optimized clinical outcomes. The analyst collaborates with clinical team members to evaluate the potential over and/or underutilization of specialty services based on clinical protocols and develops relationships with contracted provider office staff to improve healthcare outcomes.

Responsibilities

Role Responsibilities - Utilization Data Analytics

• Monitor network utilization trends and identify cost-saving opportunities.
• Identify members that require focus and are at risk of poor health outcomes.
• Work with clinical leadership to develop care plans for member cohorts.
• Track utilization management and identify service area gaps for improvement.
• Review treatment plans as assigned by the CMO to ensure necessity and appropriateness for the members.
• Work with the CMO to prioritize assigned member cohorts to ensure timeliness standards.
• Consult with network providers on improving utilization of services.
• Prepare and present analysis in a user-friendly format.
• Provide high-level customer service.

Qualifications

QUALIFICATION REQUIREMENTS:

EDUCATION:

• High School Diploma or GED required; Associates Degree in Nursing, Bachelor of Science in Nursing, or related field preferred; equivalent work experience and education will be considered in lieu of a degree.

PRIOR EXPERIENCE:

• Two (2) or more years of experience in medical management, utilization management, case management, or care coordination in an IPA or Health Plan setting preferred.

LICENSE/CERTIFICATION:

• Active Licensed Vocational Nurse (LVN) certification preferred.
• Valid California Driver's license required.

SKILLS:

• Strong verbal and written communication skills.
• Ability to establish rapport and effective working relationships with providers and health center administrators.
• Advanced proficiency in various computer applications and exemplary email communication skills.
• Ability to prioritize multiple responsibilities and manage a large workload within budget and timelines.
• Excellent problem-solving skills and self-motivation.
• Ability to develop alternative solutions to problems.
• Ability to prepare clear, concise, thorough, meaningful, and grammatically correct written reports, letters, memos, and other documents.
• Ability to independently plan, organize, prioritize, schedule, coordinate, and make decisions related to assigned responsibilities.
• Strong customer service orientation, positive attitude, and high self-motivation.
• Proficiency with Microsoft Office, especially Microsoft Excel.

The pay range for this Exempt position starts at $70,347.08 annually.

In addition, our comprehensive benefits package for regular status employees includes:

• Medical, Dental, and Vision insurance with low premium cost.
• Paid time off and paid holidays.
• 401k plan with matching contribution.
• Educational Assistance.
• Employee discounts and more!