34 Utilization Management Jobs

Responsibilities: Apply critical thinking to achieve proper clinical decisions when performing clinical reviews Utilize multiple systems and other clinical resources to achieve proper decisions in utilization management reviews Work and maneuver within queue systems that prioritize clinical reviews Be able to make a clinical decision quickly and decide and act with or without all information Evaluate opportunities for cross-benefit drug management in an integrated model Provide support to the condition-based program managers to enhance clinical affordability and total health outcome Evaluate the success of current utilization management program to determine areas of enhancement Review curren...

We are looking for a responsible Healthcare Administrator to coordinate our medical services. For this role, you should understand healthcare regulations and be able to handle medical information discretely. Healthcare Administration duties include budgeting, ordering medical supplies and maintaining employee records. Our ideal candidate has previous experience as a Healthcare Administrator and is able to complete administrative tasks accurately, and in a timely manner. Ultimately, you should be able to ensure our medical facility runs efficiently and profitably. Responsibilities Monitor budgets and prepare reports Maintain medical and staff records Track medical and office supplies stock Up...

Skill required: HM- Utilization Management - Healthcare Management Designation: Customer Service New Associate Qualifications: Any Graduation Years of Experience: 0 to 1 years About Accenture Accenture is a global professional services company with leading capabilities in digital, cloud and security.Combining unmatched experience and specialized skills across more than 40 industries, we offer Strategy and Consulting, Technology and Operations services, and Accenture Song all powered by the world's largest network of Advanced Technology and Intelligent Operations centers. Our 699,000 people deliver on the promise of technology and human ingenuity every day, serving clients in more than 120 co...

As an ideal candidate for this role, you should possess 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 based on the company's learning philosophy. Key Responsibilities: - Have 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. - Maintain a collaborative and positive attitude. - Ability to work independently, take initiative, and collaborate effectivel...

Clinical Pharmacist Role Summary Provides clinical review expertise for high dollar and complex pharmacy claims and may identify cases for potential fraud and abuse and makes referrals. This position is responsible for the supporting of formulary strategies involving both pharmacy and medical products, clinical actions following release of new/existing drug products, evaluating and managing drug utilization review, and pipeline product tracking and forecasting. Affordability solutions encompass activities that include utilization management edits at point of service, preferred drug list strategy, retrospective utilization review, risk management review and condition-specific interventions. R...

As a Technical Analyst specializing in Population Health and Care Management, your role will involve demonstrating strong domain expertise in Medicaid and other relevant healthcare programs. Your responsibilities will include working with stakeholders to identify current and future data needs, mapping Population Health and Care Management data to a normalized data model, and serving as a subject matter expert on domains such as Care Management, Utilization Management, Quality Scores, HEDIS, and Care gaps. Additionally, you will be responsible for building data concepts to support Population Health use cases and providing technology solutions to address business and technical issues for assig...

As a MongoDB Atlas Administrator in this role, you will be responsible for the following key responsibilities: - Atlas Application Administration - Performance Management and Reporting, including identifying and reporting long running queries, log management, etc - Utilization Management and Reporting - Dashboard Automation with respect to point in time failures The qualifications required for this position are as follows: - Minimum 5-6 years of experience in MongoDB administration - Proficiency in performance tuning and optimization - Strong analytical and problem-solving skills - Excellent communication and collaboration abilities Please note that the location for this position is in Chenn...

Description Consultant Technical Analyst - Population Health and Care Management Job Summary Must demonstrate strong domain expertise, particularly in the Payor-Provider ecosystem, with a solid understanding of Medicare, Medicaid, and other relevant healthcare programs Works with stakeholders to discover, clarify, and document current and future data needs Performs mapping of Population Health and Care Management data to a normalized data model. Serves as a subject matter expert on the Population health data domains such as Care Management, Utilization Management, Quality Scores, HEDIS, Care gaps Builds data concepts to support Population Health use cases Serves as a key resource for an assi...

As an Infoscion, your primary role will involve interfacing with clients for quality assurance issue resolution and ensuring high customer satisfaction. You will be responsible for understanding requirements, creating and reviewing designs, validating architecture, and delivering high levels of service offerings in the technology domain. Your tasks will include participating in project estimation, providing inputs for solution delivery, conducting technical risk planning, performing code reviews, and unit test plan reviews. Additionally, you will lead and guide your teams in developing optimized high-quality code deliverables, continual knowledge management, and adherence to organizational g...

Job Title : Clinical Coordinator (Health Plans) Job Type: Full-Time Job Location: Noida, India Department : Clinical Job Summary : The Clinical Coordinator has a well-developed knowledge and skill set in utilization management (UM), medical necessity, and care coordination. This individual is responsible for performing a variety of prospective, concurrent, and retrospective UM-related activities. These operations are primarily focused on utilization management and communications. The coordinator works with clinical team members, such as pharmacists, nurses, and pharmacy technicians, to ensure that clinical activities are completed according to accreditation and regulatory requirements. Ensur...

As an Urgent Care Clinic Supervisor at BayCare, you will play a vital role in overseeing the utilization management and daily business operations of the assigned clinics. Your responsibilities will include: - Demonstrating a clear understanding of the financial, operational, administrative, and regulatory aspects of the clinics. - Ensuring HIPAA compliance and Risk Management at the clinics. - Overseeing maintenance and purchasing for specific clinics. - Being responsible for utilization management, clinical support management, quality improvement, client relations, patient satisfaction, personnel management, and problem-solving. - Acting as a liaison to senior management. In addition to the...

BayCare is currently in search of our newest Team Member who is passionate about providing outstanding customer service to our community. We are looking for an individual seeking a career opportunity with one of the largest employers within the Tampa Bay area. Position Details Location: BayCare Urgent Care Walsingham - Largo Status: Full Time (EXEMPT) Shift: 8:00 AM to 4:30 PM Days: Monday Friday The Urgent Care Clinic Supervisor is a full-time position. Responsibilities Oversee the utilization management and daily business operations of their assigned clinics. Demonstrates a clear understanding of the financial, operational, administrative and regulatory aspects of the clinics. Ensures HIPA...

Skill required: Claims Appeals - Claims Administration Designation: Health Admin Services Analyst Qualifications: Any Graduation Years of Experience: 3 to 5 years About Accenture Accenture is a global professional services company with leading capabilities in digital, cloud and security.Combining unmatched experience and specialized skills across more than 40 industries, we offer Strategy and Consulting, Technology and Operations services, and Accenture Song all powered by the world's largest network of Advanced Technology and Intelligent Operations centers. Our 699,000 people deliver on the promise of technology and human ingenuity every day, serving clients in more than 120 countries. We e...

Skill required: Claims Appeals - Claims Administration Designation: Health Admin Services Analyst Qualifications: Any Graduation Years of Experience: 3 to 5 years About Accenture Accenture is a global professional services company with leading capabilities in digital, cloud and security.Combining unmatched experience and specialized skills across more than 40 industries, we offer Strategy and Consulting, Technology and Operations services, and Accenture Song all powered by the world's largest network of Advanced Technology and Intelligent Operations centers. Our 699,000 people deliver on the promise of technology and human ingenuity every day, serving clients in more than 120 countries. We e...

Role Overview: As a Health Admin Services Analyst at Accenture, your primary responsibility will be to provide support to the clinical team and client team in order to promote quality member outcomes, optimize member benefits, and ensure effective use of resources. Your role will involve supporting procedures that ensure adherence to medical policy and member benefits, delivering services that are medically appropriate, high quality, and cost-effective. You will also be involved in utilization management, case management, and disease management by gathering information using client-specific telephonic screening tools. Key Responsibilities: - Manage incoming and outgoing telephone calls, e-Re...

Role Overview: As the RMO Manager at our company, you will be responsible for designing, building, and managing the end-to-end talent demand and supply management process. Your main goal will be to ensure timely talent fulfillment, maximize revenue realization, and drive operational efficiency. You will closely collaborate with Commercial, Delivery, HR & Talent Acquisition, and Finance teams to align workforce strategies with business objectives. The core aspects of your role will include data-driven decision-making, demand forecasting, capacity planning, bench management, utilization improvement, process standardization, and team leadership to drive operational excellence across the organiz...

As a candidate for the position, you will be responsible for defining complex data mappings and transformations, specifically in the healthcare domain. Your role will involve working with Case Management and Utilization Management processes, necessitating a deep understanding of healthcare operations. Key Responsibilities: - Knowledge of healthcare processes, particularly Case Management and Utilization Management - Maintaining a collaborative and positive attitude in the workplace - Ability to work independently and show initiative in learning and exploring new tasks - Excellent verbal and written communication skills - Demonstrated flexibility, self-discipline, and the capability to work b...

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...