Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

This role is critical role in advancing the effectiveness and performance of the Utilization Management program. This role substantially contributes to strategic initiatives, operational improvements, and cross-functional projects that support UM program evolution, regulatory compliance, and organizational priorities. This position directly affects medical trend through execution of clinically sound and operational efficient programs and includes evaluating delegated UM services for program effectiveness and compliance. This position will gather and analyze data to identify process improvement and medical trend initiatives.The role partners with clinical leadership, cross-functional teams, and external stakeholders to ensure successful implementation of new initiatives and continuous optimization of existing processes.

• Partner with UM leadership and cross-functional teams to execute strategic initiatives that enhance utilization management programs, workflows, and outcomes.
• Support the planning, coordination, and execution of UM initiatives, including program enhancements, scope expansions, and operational improvements.
• Assist in evaluating financial, quality, and operational impacts of UM programs and proposed changes.
• Manage multiple concurrent projects, ensuring timelines, deliverables, and dependencies are effectively coordinated.
• Prepare and present relevant items for committee review as it relates to UM projects and initiatives (i.e., IUMC, MAUMC, AIGC).
• Perform monthly maintenance of the Single Source Preauthorization List. Accurately update the Single Source Preauthorization list and provide oversight of web publications to ensure information is accurately conveyed.
• Monitor and analyze relevant data following a change in preauthorization management of procedure code(s). Investigate root causes of significant data changes. Identify opportunities for process improvement or refinement. Compile review findings and provide a comprehensive summary report to UM leadership.
• Stay current on industry trends, regulatory updates, and best practices related to utilization management.
• Contribute to a culture of continuous improvement, collaboration, and accountability within UM.
• Perform ongoing analysis and periodic audits of vendor’s current systems in use including their effectiveness, usability and functionality and make recommendations for system and/or process improvements.
• Monitors and reports on Capital and delegated UM vendor project progress by tracking activity; resolving problems; publishing progress reports; recommending actions. Troubleshoots issues; responsibility for detecting potential issues and implementing solutions.
• Develop project plans and strategies in line with assigned initiatives.
• Collects and analyzes data on utilization, outcomes, safety, and costs to determine trends and identify problem areas. Lead clinical requirements; creation and review process.
• Identifies priority development and process improvement needs. Including defining use case and business need. Prioritizes project tasks, manages timelines, maintain project plans.
• Monitors utilization trends and medical cost to identify strategies for addressing trends/cost. Presents strategies for review/consideration.
• Perform other duties as assigned

Skills:

• Proficient with Microsoft Office, MS SharePoint, Excel, and Visio.
• Work experience in project management.
• Effective interpersonal and active listening skills.
• Effective written/verbal communication, physician relations and customer satisfaction skills.
• Ability to multi-task and prioritize.
• Time management skills.
• Process Improvement skills.
• Adaptability with change management skills.

Knowledge:

• Knowledge of CMS and NCQA standards for Utilization Management for health plan compliance.
• Knowledge of current and emerging clinical practice guidelines.

Experience:

• 5+ years’ experience in the health insurance, or other related healthcare field.
• 5 + years’ experience in developing and delivering training, preferably in a health related business.
• Experience in healthcare implementation
• Demonstrated excellent public speaking and written communication skills.

Education and Certifications:

• Minimum active LPN licensure required.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.    
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.