UM Analyst

Job DescriptionJob DescriptionJob Title: UM Analyst
Department: Medical Management
Supervisor (s): UM Supervisor or Manager of Medical ManagementSummaryUtilization Management (UM) Analyst represents the company by assisting leadership in ensuring regulatory compliance, accuracy, and consistency of UM processes. The Utilization Management Analyst will maintain standard compliance and performance related utilization management data. Working within prescribed guidelines and procedures, uses independent judgment requiring aggregating UM data to assist management and top professionals/specialists in selection of methods, techniques, and analytical approach to drive business goals. This role is key in collaborating with other departments to ensure appropriate claims adjudication and delivery of excellent customer service.

UM Analyst also collaborates with clinical leadership, clinical systems analyst, and other organizational departments to assure prior authorization code sets are current, and accurately configured in systems to reflect UM processes, policies, and payment rules.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Perform internal Health Plan monitoring and maintain audit tools; Including collection and distribution of data and documentation for quarterly/annual compliance committee meetings.
• Collaborates with clinical leadership, clinical systems analyst, and other organizational departments to maintain prior authorization code list and aggregate data in such a way clinical leadership can make conclusions about code list effectiveness.
• Ensure clinical code sets are accurately configured in various platforms to reflect UM processes, policies, and payment rules.
• Ensure the accuracy and reliability of data by performing regular data audits and quality checks against Medical Management systems.
• Collect data for all Health Plan audits and compile data for TDI, CMS and other regulatory body focused audits, Planned and unplanned internal audits.
• Establishes and maintains efficient filing system in paper and electronic.
• Reviews claims related disputes, and adjustment requests, summarizes for UM leadership and contributes to resolution.
• Coordinate and input service requests for a review determination by the UM Reviewer, Medical Management Manager (UM Manager) and/or Health Solutions Medical Director.
• Drafting and issuing verbal and written pre-authorization and concurrent approvals/denial correspondences and notifying providers/enrollees needed.
• Collaborating with the UM Supervisor to resolve inquiries and UM related issues received from other internal departments.
• In support of care management initiatives, identify enrollees in need of case/disease management services and collaborate with case management teams so that proactive interventions can occur.
• Performs other duties and participates in projects as assigned by immediate supervisor, Medical Management

Manager in support of compliance timelines.Job Description Minimum Qualifications

• Education: High School diploma. Certification in Medical Assistance or similar
• Previous experience in insurance utilization management or healthcare operations or a related field is preferred.
• Medical Billing or Coding program completion preferred.
• Licenses/Certifications: Certified Professional Coder (CPC®) Certification or similar certification preferred.

Experience / Knowledge / Skills:

• One (1) to two (2) years’ experience in utilization management or healthcare environment coordinating prior authorizations, care coordination or other healthcare industry setting performing functions that involve data entry. Customer service call center experience is also acceptable.
• Associate degree or higher is preferred
• Quality auding coordination and/or knowledge of relevant laws, rules, regulations and accreditation standards and requirements of a utilization management program.
• Experience with data analysis tools such as Microsoft Office Suite applications, Smartsheets, Power BI and/or Tableau
• Medical billing & coding experience is a plus. Equal or comparable experience in associated fields will be considered.

CompetenciesTo perform the job successfully, an individual should demonstrate the following competencies:
Analytical - Synthesizes complex or diverse information; collects and researches data; uses intuition and experience to complement data; Strong analytical mindset.

Job Knowledge - Competent in required job skills and knowledge; exhibits ability to learn and apply new skills; keeps abreast of current developments; requires minimal supervision; displays understanding of how job relates to others; uses resources effectively.

Problem Solving - Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics.

Communications - Expresses ideas and thoughts verbally; expresses ideas and thoughts in written form; exhibits good listening and comprehension; keeps others adequately informed; selects and uses appropriate communication methods.

Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions; demonstrates group presentation skills; participates in meetings.

Written Communication - Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information.

Managing People – This position has no direct reports.

Conflict Resolution - Encourages open communications; confronts difficult situations; maintains objectivity; keeps emotions under control; uses negotiation skills to resolve conflicts.

Adaptability - Adapts to changes in the work environment; manages competing demands; changes approach or method to best fit the situation; able to deal with frequent change, delays, or unexpected events. This position’s scheduled work hours include weekends and holidays.

Judgement - Displays willingness to make decisions; exhibits sound and accurate judgment; supports and explains reasoning for decisions; includes appropriate people in decision-making process; makes timely decisions.
Quality - Demonstrates accuracy and thoroughness; looks for ways to improve and promote quality; applies feedback to improve performance.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Education and/or ExperienceBachelor’s degree or equivalent from four-year college; or two-years related experience and/or training; or equivalent combination of education and experience.

Coding education and certification preferredLanguage SkillsAbility to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.Mathematical SkillsAbility to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.Reasoning AbilityAbility to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.Computer SkillsTo perform this job successfully, an individual should have knowledge of Contact Management systems; Database software; and MS Office products software.Certificates, Licenses, RegistrationsThis job does not require a specific certificate, license or registration, however coding certification is preferred

Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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