Summary:

The Utilization Analyst collaborates with Chief Medical Officer (CMO) and Director of Contracting and Managed Care to track medical management, quality management, and patient and provider grievances, and assist in delivering superior customer service. Works with the CMO and Director of Contracting and Managed Care to implement and manage effective utilization management processes that result in lower costs, efficient utilization of services and optimize clinical outcomes. Collaborate with clinical team members to evaluate the potential over and/or underutilization of specialty services based on clinical protocols. Develop and support relationships with contracted provider office staff that result in continued improvement in quality healthcare outcomes.

Role Responsibilities - Utilization Data Analytics  

• Monitor network utilization trends and identify cost saving opportunities
• Identify members that require focus and are at risk of poor health outcomes
• Work with the clinical leadership to develop care plans for member cohorts
• Track utilization management and identify service area gaps for improvement
• Review treatment plans as assigned by the CMO to ensure necessity and appropriateness for the members
• Work with the CMO to prioritize assigned member cohorts to ensure timeliness standards
• Work with the CMO and Director of Contracting and Managed Care to consult with network providers on improving utilization of services
• Prepare and present analysis in a user friendly format
• Provide high level customer service

QUALIFICATION REQUIREMENTS:

EDUCATION:

• High School Diploma or GED required; Associates Degree in Nursing, Bachelor of Science in Nursing degree or in a related field is preferred; equivalent work experience and education will be considered in lieu of a degree..

PRIOR EXPERIENCE:

• Two (2) or more years of experience in medical management, utilization management, case management or care coordination in an IPA or Health Plan setting preferred.

LICENSE/CERTIFICATION:

• Active Licensed Vocational Nurse (LVN) certification preferred
• Valid California Drivers license required

SKILLS:

• Strong verbal and written communication skills
• Must be able to establish rapport and effective working relationships with providers and health center administrators.
• Must have advanced proficiency in various computer applications and exemplary email communications skills.
• Must be able to prioritize multiple responsibilities and manage a large workload within budget and timelines.
• Must have excellent problem-solving skills and self-motivation.
• Must have the ability to develop alternative solutions to problems.
• Must be able to prepare clear, concise, thorough, meaningful, and grammatically correct written reports, letters, memos and other documents.
• Must be able to independently plan, organize, prioritize, schedule, coordinate, and make decisions related to assigned responsibilities.
• Must have a very strong customer service orientation, positive attitude, and be highly self-motivated, directed, and change oriented.
• Proficiency with the Microsoft Office, especially Microsoft Excel

The pay range for this Exempt position starts at $70,347.08 annually. 

In addition, our comprehensive benefits package for regular status employees includes:

• Medical, Dental, and Vision insurance with low premium cost
• Paid time off and paid holidays
• 401k plan with matching contribution
• Educational Assistance
• Employee discounts and more!