ZipRecruiter

Log In

1

Utilization Management Clinical Analyst Jobs in Colorado

Capital Rx

Clinical Account Consultant, PBM

Denver, CO · On-site

$140K - $160K/yr

Analyze pharmacy claims, utilization, and drug trend data to surface insights and build evidence-based recommendations across formulary, utilization management, specialty, and clinical programs.

Capital Rx

Principal Analyst, Analytics

Denver, CO · On-site

The Principal Analyst serves as a senior individual contributor responsible for translating complex ... clinical programs, network arrangements, utilization management initiatives, and other healthcare ...

UHS

DIR - UTILIZATION REVIEW / MGMT

Colorado Springs, CO · On-site

$85K - $120K/yr

Complete continued stay reviews with external review agencies as indicated, Maintain Utilization Management files and logs in a neat, accurate and orderly form, Provides feedback to clinical team ...

next page

Showing results 1-20

All JobsUtilization Management Clinical Analyst JobsUtilization Management Clinical Analyst Jobs in Colorado

Utilization Management Clinical Analyst information

What does a utilization management clinical analyst do?

A Utilization Management Clinical Analyst reviews and analyzes medical records, claims, and treatment plans to ensure that healthcare services provided to patients are medically necessary and cost-effective. They work with healthcare providers, insurance companies, and patients to evaluate the appropriateness of medical care based on established guidelines and policies. Their goal is to optimize patient outcomes while controlling healthcare costs and ensuring compliance with regulatory standards.

What are the key skills and qualifications needed to thrive as a utilization management clinical analyst?

To thrive as a Utilization Management Clinical Analyst, you need a solid background in healthcare, strong analytical abilities, and credentials such as RN or LPN licensure or relevant clinical certifications. Familiarity with utilization management software, electronic health records (EHRs), and claims processing systems is typically required. Excellent communication, critical thinking, and attention to detail are soft skills that help you collaborate effectively and make sound clinical determinations. These competencies are crucial for ensuring the appropriate use of medical resources, maximizing patient outcomes, and maintaining regulatory compliance.

How does a utilization management clinical analyst typically collaborate with clinical and administrative teams to ensure optimal patient care?

A Utilization Management Clinical Analyst works closely with both clinical staff, such as nurses and physicians, and administrative teams to review patient cases and ensure that treatments and services are medically necessary and align with payer guidelines. This role often involves participating in interdisciplinary meetings, communicating findings and recommendations, and helping to develop or refine care protocols. Effective collaboration is essential to balance quality patient care with cost efficiency, and analysts regularly provide feedback and support to improve clinical workflows and documentation.

What is the difference between Utilization Management Clinical Analyst vs Utilization Review Nurse?

AspectUtilization Management Clinical AnalystUtilization Review Nurse
CredentialsHealthcare degree, certifications like CCM or CUCRegistered Nurse (RN), state licensure, certifications like CCM
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, insurance companies, outpatient facilities
Employer & IndustryHealth insurance providers, managed care organizationsHospitals, insurance companies, healthcare facilities
Common Search & ComparisonUtilization Management Clinical Analyst vs Utilization Review Nurse

The main difference between a Utilization Management Clinical Analyst and a Utilization Review Nurse lies in their focus and credentials. Clinical Analysts often have healthcare degrees and certifications like CCM, working primarily in insurance or managed care settings. Utilization Review Nurses are registered nurses with licensure, working in hospitals or outpatient facilities. Both roles involve reviewing medical necessity, but their work environments and professional backgrounds differ.

What are popular job titles related to Utilization Management Clinical Analyst jobs in Colorado?

For Utilization Management Clinical Analyst jobs in Colorado, the most frequently searched job titles are:

What job categories do people searching Utilization Management Clinical Analyst jobs in Colorado look for?

The top searched job categories for Utilization Management Clinical Analyst jobs in Colorado are:

Utilization Management Clinical Analyst jobs near you
Infographic showing various Utilization Management Clinical Analyst job openings in Colorado as of August 2026, with employment types broken down into 1% As Needed, 82% Full Time, 14% Part Time, and 3% Contract. Highlights an 84% Physical, 2% Hybrid, and 14% Remote job distribution.

AVP, Utilization and Care Management Strategy

Humana Inc

Denver, CO • On-site

$180 - $230/hr

Other

This job post has expired today. Applications are no longer accepted.

Humana rating

8.0

Company rating: 8.0 out of 10

Based on 267 frontline employees who took The Breakroom Quiz

170th of 315 rated insurance

Job description

Become a part of our caring community

The AVP, Utilization and Care Management Strategy provides enterprise strategic leadership for Medicaid utilization management, care management, clinical policy governance, affordability initiatives, medical expense strategy, and performance oversight. Reporting to the VP, Medicaid Clinical Strategy and Affordability, this role leads the development and execution of a coordinated strategy designed to improve total cost of care, appropriate member access, care coordination, provider experience, quality outcomes, regulatory alignment, and program stewardship.

This is a strategy, governance, and cross-functional leadership role. The AVP is not expected to directly manage day-to-day utilization management or care management operations but will partner closely with operational leaders to shape priorities, establish strategic direction, define performance expectations, evaluate outcomes, and support scalable execution across Medicaid markets.

This leader is accountable for integrating utilization and care management strategy into a cohesive enterprise approach that supports the right care, at the right time, in the right setting, for Medicaid members. The role connects insights from authorization activity, utilization patterns, claims, denials and appeals, care management engagement, care gaps, admissions, emergency department use, post-acute utilization, high-risk member needs, and provider practice variation to inform enterprise strategy and market-level action.

The AVP serves as a strategic liaison to Medicaid market leadership and partners across Clinical Operations, Population Health Management, Behavioral Health, Pharmacy, Care Management, Network, Finance, Actuarial, Quality, Analytics, Payment Policy, Payment Integrity, and SIU. The role aligns enterprise utilization, care management, and affordability strategies with market realities, advances scalable solutions, and ensures disciplined governance across a significant clinical and financial performance domain.

This role is open to a physician leader and also to other highly qualified clinical or healthcare executives with deep experience in Medicaid managed care, utilization management, care management, clinical strategy, medical cost management, and complex matrixed leadership.

Use your skills to make an impactResponsibilities

  • Lead enterprise Medicaid utilization and care management strategy, including prior authorization strategy, Medicaid clinical policy governance, medical expense strategy, site-of-care optimization, provider practice variation, high-risk member strategy, and targeted affordability initiatives.

  • Establish strategic direction, governance routines, performance expectations, and enterprise priorities for Medicaid utilization and care management, in partnership with operational leaders accountable for day-to-day execution.

  • Oversee Medicaid care management strategy at the enterprise level to ensure programs are member-centered, data-driven, clinically effective, operationally scalable, and aligned with utilization, quality, access, regulatory, and affordability goals.

  • Integrate utilization management and care management strategies to identify members with rising risk, complex needs, avoidable utilization, care gaps, and opportunities for earlier intervention, improved care coordination, and more appropriate site-of-care decisions.

  • Use utilization, authorization, denial, appeal, claims, care management, quality, medical expense,

#J-18808-Ljbffr

What Humana employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Humana logo

About Humana

Sourced by ZipRecruiter

Humana Inc., headquartered in Louisville, KY., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Louisville, KY, US

Year founded

1961

Social media

FacebookTwitter

View All Humana Jobs

Apply