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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 overseeing interdepartmental collaboration in the monitoring and submission processes for initial and renewal applications related to Utilization Review (UR) state licenses. This position necessitates close cooperation with legal teams and industry experts to perform regulatory research concerning licensing and compliance, while also engaging with both internal and external stakeholders to relay pertinent information and requirements.

Key Responsibilities:

  • Maintain comprehensive 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 requirements.
  • Work alongside legal teams to monitor state licensing obligations and implement necessary changes.
  • Assist in the development, execution, monitoring, and refinement of quality improvement and utilization management initiatives.
  • Support the implementation and maintenance of RBUM policies, procedures, and processes.
  • Contribute to quality improvement initiatives, including monitoring, auditing, and tracking of the Utilization Management Program.
  • Coordinate with various departments to assist in conducting required internal audits related to UM.
  • Partner with management to formulate quality assurance plans, collaborate with employees on strategy implementation, and review documentation for precision.
  • Engage in URAC and NCQA accreditation program standards and surveys, as well as any other accreditation programs adopted by the organization.
  • Assist with client audits and routine compliance activities.
  • Perform additional responsibilities as assigned by management.

Qualifications:

Experience:

  • Minimum of 2 years of relevant work experience.

Education:

  • High School Diploma or GED (Required).

Preferred Skills:

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

Additional Experience:

  • Experience in policy review and report development to support NCQA/URAC accreditations.
  • Proficiency in organizing, tracking, and trending information.
  • Familiarity with Utilization Management Licenses on a national scale.
  • Experience in conducting internal audits.

Education:

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

Certifications:

  • CHC certification is preferred.

Working Conditions:

  • This is a remote position with no travel requirements.

Physical Demands:

  • Primarily sedentary work, requiring minimal physical exertion.

Compensation and Benefits:

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

About Premier:

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

Premier is committed to fostering a diverse and inclusive workplace, ensuring equal opportunity for all qualified applicants.