Key Responsibilities • Data Analysis & Reporting: Analyze utilization trends, claims data, and pharmacy data to identify cost-containment opportunities. • Workflow Optimization: Document, review, and enhance UM processes (intake, concurrent review, appeals). • System Enhancement: Define business requirements for IT solutions and conduct user acceptance testing (UAT) for UM software. • Regulatory Compliance: Ensure all UM processes comply with state/federal regulations and accreditation standards. • Cross-functional Collaboration: Act as a liaison between clinical staff (nurses, medical directors) and IT/leadership. Required Skills and Qualifications • Experience: 3-5+ years in UM, care management, or managed care settings. • Technical Proficiency: Strong SQL skills, data visualization tools (e.g., Tableau, Power BI), and electronic health records (EHR/EMR). • Knowledge: Deep understanding of healthcare coding (ICD-10, CPT), claims, and insurance regulations. • Education: Bachelor’s degree in Healthcare Administration, Nursing, or related field. • Clinical Background: RN or LPN license is highly preferred for clinical data interpretation. Common Tools Used • SQL and relational databases. • Data analysis software (Excel, SAS, SQL). • Workflow modeling tools (Visio). • Reporting platforms (Tableau, Power BI).