Utilization Management Analyst

What are important things that YOU need to know about this role?
* We're launching a brand-new role driven by fresh healthcare regulations-and you'll help build it from the ground up!
* Be a key player in designing processes for a newly created position
* If you love diving into data, solving puzzles with root cause analysis, and flexing your SQL skills, this is your playground. You'll collaborate with both clinical and business teams, making a real impact in the healthcare space.
* This is a remote role with core hours of Monday-Friday, 8 AM - 5 PM CST, but we offer flexibility so you can make the schedule your own. Occasional weekend coverage keeps things interesting.

What will YOU be doing for us?
Provide technical and project coordination and analysis to the clinical and administrative utilization management/authorization department to ensure authorization service level agreements (SLAs) are met in accordance with contractual obligations and in compliance with regulatory requirements. Analyze, monitor and resolve trends identified. Utilize internal practices and policies to conduct audits of authorization case work performed by the administrative and clinical team. Determine root cause of quality issues and processing errors and recommend and implement appropriate solutions/controls to eliminate future errors.

What will YOU be working on every day?
* Coordinate and implement department projects, participating in internal and client calls as necessary.
* Analyze and validate audit findings according to internal standards, client contractual requirements, URAC/NCQA standards, and relevant state/government regulations.
* Provide trending analysis from audit and reporting results.
* Perform daily audits of authorization turnaround times to ensure compliance is met, coordinating completion when necessary.
* Perform audits to support the administrative and clinical branches of the Utilization Management team
* Maintain current knowledge of Utilization Management/Authorization policies and procedures, URAC and NCQA standards.
* Identify trends in processing errors and/or quality related issues, determine root cause, and bring potential resolutions to management.
* Work with management staff to resolve any processing issues leading to audit concerns, leading efforts for SKYGEN's Internal Priority Quality Improvement (IPQI) processes recommending controls and post implementation monitoring.
* Provide technical assistance to the clinical and administrative team to include, but not be limited to: system set up, attachment vendor set up, system issue coordination, onboarding training.
* Communicate with management and other internal staff on audit findings and provide any appropriate process change recommendations.
* Act as a SME while working with SKYGEN Reporting Team, by reviewing monthly reports and providing feedback on client reporting elements for standard and ad-hoc report requests.
* Act as a SME in tandem with the authorization supervisor and lead dental consultants, along with staff assigned daily compliance performance and alert management to any instance where compliance might be compromised.
* Configuration of authorization set up in the Enterprise System.
* Work with External Audits, as needed, while responding to client audit requests engaging management staff when necessary.
* Work with management staff to resolve any processing issues leading to audit concerns.
* Work with management staff to investigate, analyze and resolve high priority items.

What qualifications do YOU need to have to be GOOD candidate?
* High school diploma or equivalent
* 4 plus years of job-related experience
* 5 plus years of experience in root cause analysis, deciphering data, and mitigating risk
* Excellent computer literacy including strong proficiency in Microsoft Office
* Excellent ability to organize work appropriately ensuring deadlines are met
* Excellent high attention to detail and accuracy
* Intermediate knowledge of SQL
* Ability to remain organized with multiple interruptions
* Ability to communicate effectively with others including both internal and external customers

What qualifications do YOU need to have to be a GREAT candidate?
* Associates degree or Bachelor's degree
* Two or more years in a quality role
* Experience with healthcare terms
* Knowledge of dental and vision claims payment and billing processes
* Knowledge of general practices for appeals, complaints, and grievances handling
* Knowledge of federal and state regulations as it pertains to health care compliance

The salary range is listed below for your reference. Please keep in mind that your education and experience along with your knowledge, skills and abilities are taken into consideration when determining placement within the range.