17 Utilization Management Jobs

As an ideal candidate for this role, you should have 2-3 years of experience and hold a Bachelor's degree in Computer Science, Information Systems, Healthcare, or a related field. Continuous learning is crucial in alignment with the company's learning philosophy. Key Responsibilities: - Possess 5-7 years of experience in gathering requirements to define complex data mappings and transformations, particularly in a managed care environment with a background in Case Management and Utilization Management in healthcare. - Demonstrate a strong understanding of healthcare processes. - Exhibit a collaborative and positive attitude. - Ability to work independently and take initiative. - Excellent ver...

As the leading cloud-based platform provider for the mortgage finance industry, ICE is dedicated to enabling lenders to increase loan origination, reduce origination costs, and shorten the time to close loans, all while ensuring the highest levels of compliance, quality, and efficiency. As the Service Manager, your role will involve building and leading a new team to operational success. Your responsibilities will include hiring, training, and overseeing a team that provides technology-enabled services to US-based mortgage companies. You will be the escalation point for overcoming any obstacles to service delivery, ensuring data security, and documenting standard operating procedures (SOPs) ...

As a Sr. Process Associate- Behavioral Healthcare Billing at Med Karma, you will be responsible for handling medical billing solutions for healthcare providers specializing in behavioral health. With a minimum of 3 years of experience in this field, you will demonstrate expertise in behavioral health billing, coding, and reimbursement policies. Your role will involve managing a wide range of billing functions, including utilization management, prior authorization, claims review, and analyzing denials to develop effective appeal strategies. You should possess good communication skills and a strong understanding of revenue codes related to IOP/PHP services. Additionally, you must navigate carv...

About Evernorth: Evernorth Health Services, a division of The Cigna Group (NYSE: CI), creates pharmacy, care, and benefits solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention, and treatment of illness and disease more accessible to millions of people. Data Measurement & Reporting Lead Analyst Excited to grow your career We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position, you see is right for you, we encourage you to apply! Our people make all the difference in our success. ROLE SUMMARY: Evern...

As a Business Systems Analyst in the healthcare industry, you will utilize your 7-10 years of experience to drive success in Utilization Management. Your strong domain knowledge will be key in managing workflows for prior authorization, concurrent review, retrospective review, and clinical guidelines. An understanding of HIPAA, CMS, and health plan operations is essential for this role. Experience in Agile/Scrum and Waterfall project environments will allow you to thrive, while proficiency in tools like JIRA, Confluence, Visio, Excel, and SQL will be beneficial for data validation and analysis. Your excellent documentation skills in BRDs, FRDs, user stories, and process flows will ensure cle...

Position Overview We are seeking a skilled and dedicated MongoDB Atlas Administrator to join our dynamic team in Chennai. This full-time position offers an exciting opportunity to work with cutting-edge technology in a collaborative environment. The ideal candidate will have a strong background in database management and a passion for optimizing performance and ensuring data integrity. With an annual salary of 10,00,000, this role is perfect for professionals looking to advance their careers in database administration. Key Responsibilities As a MongoDB Atlas Administrator, you will be responsible for a variety of tasks that are crucial to the smooth operation of our database systems. Your ke...

As a valued member of the Infosys delivery team, you will be responsible for collaborating with clients to resolve quality assurance issues and ensuring their utmost satisfaction. Your key duties will include comprehending requirements, designing and reviewing solutions, validating architectures, and delivering top-notch service offerings in the technology sector. Furthermore, you will play a crucial role in project estimation, contribute to solution delivery, conduct technical risk assessments, oversee code reviews and unit test plan evaluations. Your leadership will be instrumental in guiding your teams towards creating optimized, high-quality code deliverables, promoting continuous knowle...

The Resource Management Manager role involves overseeing resource planning, allocation, and utilization within the Organization. Your responsibilities include ensuring that resources are assigned to projects at the right time, balancing workload distribution, optimizing capacity, and supporting business objectives. You will collaborate with Directors, Project Managers, external stakeholders, and HR to maintain workforce efficiency, track skills, plan skill upgrades, project allocations, and anticipate future resource needs. You will lead the workforce planning process and demand intake process to achieve optimal resource allocation across projects and teams. Working closely with delivery dir...

The RMO Manager is responsible for designing, building, and managing the end-to-end talent demand and supply management process to ensure timely talent fulfillment, maximize revenue realization, and drive operational efficiency. This role entails close collaboration with Commercial, Delivery, HR & Talent Acquisition, and Finance teams to align workforce strategies with business objectives. The key aspects of this role include data-driven decision-making, demand forecasting, capacity planning, bench management, utilization improvement, process standardization, and team leadership to enhance operational excellence across the organization. Responsibilities Talent Demand & Supply Management: - D...

As a Registered Nurse (RN) with active, unrestricted license in [state], your primary responsibility will be to review and assess clinical information submitted with Prior Authorization (PA) requests to determine medical necessity, appropriateness, and benefit coverage. You will conduct clinical evaluations for outpatient, inpatient, and specialty services, including J-code medications and durable medical equipment (DME) as applicable. It will be essential for you to apply CMS Medicare Advantage guidelines, internal policies, and clinical criteria (such as MCG/InterQual) to make informed decisions. Collaboration will be a key aspect of your role as you work closely with physicians, pharmacis...

Role & responsibilities Come join our team! Help us tackle the data usability challenge for payers. Your expertise and experience will help drive meaningful performance outcomes. You'll also have the chance to advance your career, acquire new skills, and collaborate with some of the most innovative minds in payer data management. We are seeking an experienced Business Analyst with Utilization Management and Care Management subject matter expertise to join our growing team. You will act as a liaison between business stakeholders, the data modeling team, and technical teams, ensuring client needs and business requirements are translated into actionable technical specifications resulting in sea...

Profile Overview:We are looking for an experienced professional in the FLYASH Thermal sector, who will oversee and manage business operations at the assigned Thermal power plant by setting up the entire operations team for flyash disposal. Job Description Responsible for setting up the entire operations team. Assisting and overseeing the site engaged in disposing ash from Thermal power for both fly and legacy ash disposal as per the margins agreed by the management. Monitor the work progress on a regular basis and formulate reports as required (daily, weekly monthly, yearly planning etc) Arranging local transporters from power plants to mines/low-lying areas and ensuring that the vehicles ru...

Profile Overview: We are looking for an experienced professional in the FLYASH Thermal sector, who will oversee and manage business operations at the assigned Thermal power plant by setting up the entire operations team for flyash disposal. Job Description Responsible for setting up the entire operations team. Assisting and overseeing the site engaged in disposing ash from Thermal power for both fly and legacy ash disposal as per the margins agreed by the management. Monitor the work progress on a regular basis and formulate reports as required (daily, weekly monthly, yearly planning etc) Arranging local transporters from power plants to mines/low-lying areas and ensuring that the vehicles r...

Responsibilities: * Loading of FLYASH from silo or dykash * Unloading of flyash in mines or highways* Trip or fleet management * Daily trip management of vehicles* Responsible to handle smooth operations of ash discharge* Responsible to handle smooth fleet operations, loading and unloading of ash in vehicles.* Proper planning of manpower as and when required.* Loading of ash from the silo to Hywa, dumpers and assigning bills.* Handle contractors and vendors for smooth ash disposal from the sites. * Operate the ash unloading equipment and drive the ash-hauling trucks to dispose of the coal ash. Desired Profile:* Any graduate with 1 to 8 yrs of experience in FLY ash management.* Excellent rela...

Profile Overview: We are looking for an experienced professional in the FLYASH Thermal sector, who will oversee and manage business operations at the assigned Thermal power plant by setting up the entire operations team for flyash disposal. Job Description Responsible for setting up the entire operations team. Assisting and overseeing the site engaged in disposing ash from Thermal power for both fly and legacy ash disposal as per the margins agreed by the management. Monitor the work progress on a regular basis and formulate reports as required (daily, weekly monthly, yearly planning etc) Arranging local transporters from power plants to mines/low-lying areas and ensuring that the vehicles r...

Profile Overview: We are looking for an experienced professional in the FLYASH Thermal sector, who will oversee and manage business operations at the assigned Thermal power plant by setting up the entire operations team for flyash disposal. Job Description Responsible for setting up the entire operations team. Assisting and overseeing the site engaged in disposing ash from Thermal power for both fly and legacy ash disposal as per the margins agreed by the management. Monitor the work progress on a regular basis and formulate reports as required (daily, weekly monthly, yearly planning etc) Arranging local transporters from power plants to mines/low-lying areas and ensuring that the vehicles r...

Role & responsibilities We are seeking a dedicated Utilization Management Specialist to join our Chennai office. In this role, you will be responsible for reviewing and analyzing clinical information to determine the medical necessity and appropriateness of healthcare services, ensuring compliance with established guidelines and policies. Your expertise will contribute to optimizing patient care and resource utilization. Key Responsibilities Conduct prior authorization, concurrent, and retrospective reviews for various healthcare services, including inpatient, outpatient, home health, and behavioral health. Apply evidence-based criteria (e.g., MCG, InterQual) to assess the necessity of medic...