Quality and Utilization Management Specialist

Quality and Utilization Management Specialist What you will be doing:

The Quality and Utilization Management Specialist will be the owner of, and the primary individual responsible for interdepartmental coordination of monitoring and preparing submissions for initial and renewal of Utilization Review (UR) state licenses. This role will work closely with legal and other industry resources to conduct regulatory research for licensing and compliance and working collaboratively with internal/external stakeholders to communicate current and relevant information and requirements.

This position will also support the Sr. Director, Quality and Utilization Management in developing, implementing, monitoring and updating quality improvement and utilization management initiatives as well as policies, procedures and processes. Provides support for URAC and NCQA accreditation program standards and surveys, as well as any other accreditation program as adopted by the company. This role will require to stay apprised of regulatory changes, guidance, and industry developments relating to compliance, quality, and utilization management.

• Documenting and tracking of all licensing requirements and application statuses.
• Work with internal departments and outside vendor(s), as applicable, for the timely completion and submission of licensing requirements.
• Coordinate with legal to monitor all state licensing requirements and implement changes as identified.
• Provide support in developing, implementing, monitoring and updating quality improvement and utilization management initiatives.
• Assist with implementing and maintaining RBUM policies, procedures and processes.
• Support quality improvement initiatives, including but not limited to: monitoring, auditing, and tracking of Utilization Management Program.
• Coordinate with other departments and assist as needed in performing/monitoring required UM internal audits.
• Collaborating with management to develop quality assurance plans, working with employees to implement the strategies, and reviewing documents for accuracy.
• Assists with URAC and NCQA accreditation program standards and surveys, as well as any other accreditation program as adopted by the company.
• Assist with client audits and routine compliance tasks.
• Other responsibilities as assigned by Stanson management.

Work Experience:

2 or more years.

Education:

High School Diploma or GED (Required).

• Demonstrated ability to assume responsibility for daily activities and projects without direct supervision, including working within time frames to meet deadlines.
• Demonstrated experience with written communications and document preparation.
• Demonstrated organizational skills with strong attention to detail and quality.

• Experience in organization, tracking, and trending of information.
• Experience with Utilization Management Licenses (Nationwide).
• Experience with NCQA/URAC accreditation.
• Experience with internal auditing.

• Associate's degree or equivalent experience in compliance.

• CHC, preferred.

• Remain in a stationary position for prolonged periods of time.
• Be adaptive and change priorities quickly; meet deadlines.
• Attention to detail.
• Operate computer programs and software.
• Ability to communicate effectively with audiences in person and in electronic formats.
• Day-to-day contact with others (co-workers and/or the public).
• Making independent decisions.
• Ability to work in a collaborative business environment in close quarters with peers and varying interruptions.

No travel required.

Physical Demands:
Sedentary. Exerting up to 10 pounds of force occasionally or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves remaining stationary most of the time. Jobs are sedentary if movement is required only occasionally, and all other sedentary criteria are met.

• Health, dental, vision, life and disability insurance.
• 401k retirement program.
• Paid time off.
• Participation in Premier's employee incentive plans.
• Tuition reimbursement and professional development opportunities.

• Ranked #1 on Charlotte's Healthiest Employers list for 2019, 2020, 2022, and 2023 and 21st Healthiest Employer in America (2023).
• Named one of the World's Most Ethical Companies by Ethisphere Institute for the 16th year in a row.
• Modern Healthcare Best in Business Awards:
  Consultant - Healthcare Management (2024).
• The only company to be recognized by KLAS twice for Overall Healthcare Management Consulting.

For a listing of all of our awards, please visit the Awards and Recognition section on our company website.

• Perks and discounts.
• Access to on-site and online exercise classes.

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