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Utilization Review and Quality Assurance Specialist

2 months ago

Charlotte, North Carolina, United States Premier, Inc. Full time

Position Overview:

The Quality and Utilization Management Specialist is a pivotal role responsible for the comprehensive oversight of interdepartmental collaboration in monitoring and preparing submissions for the initiation and renewal of Utilization Review (UR) state licenses. This position necessitates close cooperation with legal teams and industry experts to conduct thorough regulatory research pertinent to licensing and compliance, while also engaging with both internal and external stakeholders to relay essential information and requirements.

Key Responsibilities:

  • Maintain detailed documentation and tracking of all licensing prerequisites and application statuses.
  • Collaborate with internal departments and external vendors to ensure timely completion and submission of licensing obligations.
  • Work alongside legal teams to oversee all state licensing mandates and implement necessary adjustments as identified.
  • Assist in the development, execution, monitoring, and refinement of quality enhancement and utilization management initiatives.
  • Support the establishment and maintenance of RBUM policies, procedures, and processes.
  • Engage in quality improvement efforts, including but not limited to the monitoring, auditing, and tracking of the Utilization Management Program.
  • Coordinate with various departments to assist in conducting required internal audits related to UM.
  • Collaborate with management to formulate quality assurance strategies, working with staff to implement these strategies and review documentation for precision.
  • Support URAC and NCQA accreditation standards and surveys, along with any other accreditation programs adopted by the organization.
  • Assist with client audits and routine compliance activities.
  • Undertake additional responsibilities as assigned by management.

Qualifications:

Work Experience: Minimum of 2 years of relevant experience.

Education: High School Diploma or GED (Required).

Preferred Skills:

  • Proven ability to manage daily activities and projects independently, meeting deadlines effectively.
  • Strong written communication skills and experience in document preparation.
  • Exceptional organizational skills with a keen attention to detail and quality.

Experience:

  • Experience in organizing, tracking, and trending information.
  • Familiarity with Utilization Management Licenses on a national scale.
  • Experience with NCQA/URAC accreditation processes.
  • Background in internal auditing.

Education:

  • Associate's degree or equivalent experience in compliance is preferred.

Certifications:

  • CHC certification is preferred.

Additional Requirements:

  • Ability to remain stationary for extended periods.
  • Flexibility to adapt and shift priorities quickly; ability to meet deadlines.
  • Strong attention to detail.
  • Proficient in operating computer programs and software.
  • Effective communication skills with diverse audiences, both in person and electronically.
  • Frequent interaction with co-workers and/or the public.
  • Capacity to make independent decisions.
  • Able to work collaboratively in a dynamic business environment.

Working Conditions: Remote; no travel required. Physical demands are primarily sedentary, involving minimal exertion.

Compensation and Benefits:

Premier offers a competitive salary range and a comprehensive benefits package, including health, dental, vision, life and disability insurance, a 401k retirement program, paid time off, and opportunities for professional development.

About Premier:

  • Recognized as one of the top employers for health and wellness.
  • Awarded for ethical business practices and excellence in healthcare management consulting.

Premier is committed to fostering a diverse and inclusive workplace. We welcome applicants from all backgrounds and experiences.