Oversee and implement initiatives aimed at improving UM operations, including but not exclusive to provider redirection, cost control, and process automation.
Identify inefficiencies in UM workflows and propose data-driven and process improvements.
Support the rollout of various UM programs and initiatives
Ensure that operational projects align with company goals for medical utilization cost containment.
Analyze medical utilization patterns, claims data, provider performance and programs performance and identify cost drivers and areas for improvement.
Work with the different key stakeholders to identify requirements such as development of dashboards, reports, and insights that support UM strategies.
Monitor and track key metrics such as LOA issuance rates, outlier detection trends, and cost savings achieved.
Collaborate with other UM, Medical, PNM, and Operations teams to execute projects and align strategies.
Provide regular updates to management on operational performance and project outcomes.
Implement UM policies related to utilization cost management and ensure adherence across operational workflows.
Assist in the formulation and execution of policy changes to enhance cost efficiency without compromising care quality.
Ensure compliance with regulatory requirements and internal guidelines.
Monitor patient outcomes to ensure that cost-control measures do not negatively impact healthcare quality.
Identify and mitigate risks associated with high-cost cases and chronic disease management.
Support UM leadership in implementing corrective actions when utilization patterns indicate potential inefficiencies or risks.
Experience And Training
At least 3–5 years of experience in utilization management, healthcare operations, or project management.
Strong analytical skills with experience in data-driven decision-making.
Proficiency in project management tools (e.g., Asana, Trello, Jira) and data visualization platforms (Power BI, Google Sheets).
Excellent communication and stakeholder management skills.
Ability to work across teams and manage multiple operational projects simultaneously.
Knowledge of healthcare utilization, claims processes, and provider negotiations is an advantage.
