Utilization Analyst Jobs in California (NOW HIRING)

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At Hill Physicians Medical Group, we're shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

The Utilization Management Business Analyst will serve as a critical link between our Authorizations operations and IT teams, focusing on optimizing the utilization management workflows within the Epic system. This role will analyze business processes, design solutions, and support the implementation and maintenance of the Epic Utilization Management module to enhance operational efficiencies and ensure compliance with regulatory requirements. This role will report to Manager, Authorizations Business Product Management.

Essential responsibilities:

• System Support: First tier support for Utilization Management team and integrated team workflows with, Compliance, Contracting, Concurrent review, Enrollment, Claims, Customer Services, Regional Services and Provider data teams. Route and track complex issues, system configuration requests to IT and other teams as necessary.

• Analysis & Solutioning: Conduct analysis for issues identified. Intake enhancement requests and recommend potential system solutions.

• Requirements gathering: Gather business requirements from necessary business stakeholders. Secure leadership approval of the requirements and system workflow/design as necessary.

• Testing: Point person for all testing needs for system updates - Operational changes, enhancements, reports, and projects.

• Key operational reports: Generate and distribute reports using Epic Reporting Workbench (RWB) for UM Leadership and Compliance Audits. Perform necessary data analysis to present summaries and recommendations relevant to the audience. Collaborate with Informatics team for complex reports, dashboards.

• System adoption: Distribute announcements for system updates and participate in system demonstration, training content creation as necessary. Coordinate to ensure operationalization of system workflow changes working with internal and external stakeholders.

• Adjudication Rules: Own adjudication rules monitoring, maintenance, and identify opportunities to improve auto approval rate in Tapestry, in collaboration with Business and IT Teams.

• Codes maintenance: Own procedure codes and code levels maintenance, in collaboration with Business and IT Teams.

• Codes analysis: Participate in analysis and present recommendations for codes monitoring and outliers identified by Informatics team(s)

• Workflow optimizations: Own integrated UM workflows in Tapestry, in collaboration with Business and IT Teams

• Work queues: Own WQ routing and maintenance, in collaboration with Business and IT Teams

• IT Project participation: Participate in Epic IT projects representing the department, mitigating potential risks to Utilization Management team KPIs - Electronic adjudication (EA) rate, Turnaround time (TAT) compliance and pending work queue volumes.

• Data Governance: Participate in Data Governance stewardship meetings and initiatives representing -Utilization Management team to identify and solve for the team's data needs.

Skills and Experience:

• Epic Tapestry UM/CM or other related modules certification required.

• A minimum of 3 years of experience with Epic Reporting Workbench required.

• A minimum of 3 years of experience as Business/Systems Analyst or similar position required.

• Demonstrated ability to elicit, analyze and communicate business requirements effectively.

• Ability and willingness to build positive relationships with internal and external teams.

• Excellent communication, critical and analytical thinking, and problem-solving skills.

• Ability to exercise good judgment and prioritize multiple tasks.

• Ability to work independently, showing initiative and being pro-active.

• Proficient with MS Office: Excel, Outlook, Word, Teams and PowerPoint.

Additional Information:

Salary: $100,000 - $127,000 Annual

Hill Physicians is an Equal Opportunity Employer