Job Description
Utilization Analyst (Medical)
Elite Technical is seeking a Medical/Clinical Utilization Analyst to support our customer, a health plan in the BWI Maryland area. The selected candidate will assure that our client health plan-s remains competitive by identifying, designing, recommending, implementing and evaluating health care programs that control utilization and benefit expense. This position is responsible for the identification, design, development, implementation and evaluation of programs that control utilization and benefit expense. The selected candidate will negotiate and maintain vendor agreements and fosters cooperative business relationships with contracted vendors to ensure proper PPO savings. Specific responsibilities include:
-Analyzes qualitative and quantitative data to support program strategies, implications of contract business terms and make recommendations for new initiatives.
-Directs program implementation projects, assuring effective coordination of all Health Plan operations relative to conversion, start-up, ongoing operation and impact analysis.
- Provide financial and utilization analysis of existing Utilization Programs
-Identify key cost and utilization factors driving medical expense to determine types of services to be managed/controlled.
-Implement monitoring and reporting systems to measure program and vendor performance against expectations and contractual commitments.
- Identify and seek out potential programs and vendors that support utilization management and makes recommendations to senior staff on initiatives and strategies that support the corporate mission
- Advise on industry trends and identifies the need for new or revised utilization management programs and practices
- Direct quarterly trend reviews and forecasting analysis
- Other duties as assigned.
This position is a fulltime/direct position with our customer. The selected candidate will have to be onsite 5x per week for the first few weeks for training, then will be primarily remote (1-2x onsite per month). Want to learn more? Then you should contact Elite Technical right away for consideration!
Required Skills
- BA/BS degree is highly preferred.
- Seeking 5+ years of Clinical / Medical / Payor experience
- LPN or RN certification is required. Recently expire certifications is acceptable.
- Must have outstanding Knowledge/Experience with medical benefit management and plan design, pharmacy benefit management and plan design, medical coding, medical and behavioral case management, familiarity with medical and pharmaceutical policies and industry standards. Career evolution from Clinical to Payor organization would be preferred.
- Ability to define data and information needs; compile, analyze and interpret data relative to healthcare utilization.
- Outstanding writing and verbal skills are critically important. Ability to write reports, recommendations, business correspondence, scope of work, project plans, policies and procedures. Ability to effectively present information to Health Plan Management and effectively communicate with vendor/partners and members.
- Detail oriented with strong analytical, presentation and research skills a must.
- Strong performance management skills in managing external partners, communicating clear goals, performance measurements, etc.
- Demonstrated ability to identify problems, collect data from various sources and determine the appropriate action.
- Excellent computer skills in Microsoft Office, internet research and Ad hoc query and reporting.
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Job Tags
Full time, Contract work, Work at office, Remote work,