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Utilization Analyst Jobs in Tennessee (NOW HIRING)

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GIS Developer/Analyst

Memphis, TN

GIS Developer/Analyst. Requisition ID : SAIC CoM 2017 -MC R214157. Client: City of Memphis(State of ... Provide expert utilization of ArcGIS Online technologies to develop applications Provide some ...

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Utilization Analyst information

What is the difference between Utilization Analyst vs Data Analyst?

AspectUtilization AnalystData Analyst
Required CredentialsBachelor's in healthcare, business, or related field; certifications like CPC or HCISPPBachelor's in statistics, computer science, or related field; certifications like CAP or Microsoft Certified Data Analyst
Work EnvironmentHealthcare facilities, insurance companies, or healthcare consulting firmsVarious industries including finance, marketing, healthcare, and technology
Employer & Industry UsageUsed primarily in healthcare and insurance sectors to optimize resource utilizationUsed across multiple industries to analyze data trends and support decision-making

While both roles involve analyzing data, a Utilization Analyst focuses on healthcare resource management and efficiency, whereas a Data Analyst has a broader scope across industries, analyzing diverse data sets to inform strategic decisions.

What does a utilization analyst do?

A utilization analyst monitors and analyzes the use of resources, such as staff or equipment, to ensure efficiency and cost-effectiveness. They often work with data management tools and generate reports to identify areas for improvement in resource allocation and productivity.

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Utilization Analyst jobs near you

Utilization Management Nurse

archwellhealth

Nashville, TN

Full-time

Re-posted 7 days ago

Job description

Job Summary:

Reporting to the Director of Utilization Management, the Utilization Management Nurse is responsible for ensuring that patients receive appropriate, cost-effective care by reviewing and evaluating medical services, treatments, and procedures. This role identifies trends for opportunities to educate and collaborate with healthcare providers, patients, and specialists to optimize resource utilization and improve patient outcomes.

Duties/Responsibilities:

 

  • Conducts prospective, concurrent, and retrospective utilization reviews for medical necessity to ensure treatment and services are appropriate and necessary by reviewing medical records and treatment plans.
  • Works collaboratively with healthcare providers and Medical Directors to provide guidance on approvals or requests for health plan determination reviews as applicable utilizing CMS clinical guidelines and insurance policies.
  • Maintains accurate and detailed records of reviews, interventions, and communications to ensure adherence to health plan requirements and organizational policies.
  • Analyze utilization trends to ensure progress towards organizational goals
  • Educates healthcare providers and patients regarding appropriate levels of care and service criteria and guidelines.
  • Collaborates with Network and specialists to identify opportunities to educate on value-based care, resolve specialty gaps by markets, improve cost-effectiveness and coordination of care to meet patient needs.

Required Skills/Abilities:

  • Strong knowledge of utilization management functions in value-based care, including data analysis, claims review, reimbursement practices, and medical records reviews.
  • Thorough, in-depth knowledge of evidence-based practice, legal rules and regulations and best practices in healthcare
  • Ability to effectively leverage business and organizational knowledge within and across functional areas
  • Must possess a high degree of emotional intelligence and integrity, driven and focused work ethic
  • Continuous desire to learn and embrace new methods; ability to adapt and be resilient.
  • Self-starter with the ability to think creatively and work effectively
  • Ability to build a relationship and work effectively with various seniorities and diverse populations.
  • Excellent critical reasoning, decision-making, and problem-solving skills to make informed decisions and ensure effective resource utilization while maintaining quality patient care.
  • Willingness and ability to travel, up to 20%

Education and Experience:

 

  • AA/AS degree in Nursing required; BA/BS degree in Nursing (BSN) or Healthcare Administration preferred
  • A valid, active Registered Nurse (RN) license in state(s) of employment required
  • A minimum of 3 years’, current direct utilization management required 
  • Work in an acute care facility, community-based clinic, public health department or specialization with the senior population preferred
  • Proficient PC skills
  • Fluency in Spanish or other languages spoken by people in the communities we serve is desirable, but not required

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.

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