Description

GENERAL OVERVIEW: 

Assures the highest standards of clinical quality and regulatory compliance across Utilization Management department activities for all government lines of business and delegated vendors, playing a critical role in maintaining accreditation and evolving regulatory landscapes. The individual in this role will confirm Utilization Management’s compliance with federal, state, and regulatory guidelines (e.g., NCQA, CMS), assisting with policies and procedures, and continually monitoring regulatory changes. The specialist is the key individual responsible for collecting, analyzing, and interpreting clinical data, clinical outcomes, and performance metrics to prepare comprehensive reports and audit responses, including UM program descriptions and evaluations. Additionally, this role involves working closely with utilization management leadership and other departments to resolve issues and provide education on regulatory requiremen...