Assistant Manager-Utilization Management

Responsibilities

Operational Execution & Process Improvement

• 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.