Assistant Manager-Utilization Management

Responsibilities Operational Execution & Process Improvement Oversee and implement initiatives aimed at improving UM operations, including but not exclusive to provider redirection, cost control, and process automation. Identify inefficiencies in UM workflows and propose data-driven and process improvements. Support the rollout of various UM programs and initiatives Ensure that operational projects align with company goals for medical utilization cost containment. Data Analysis & Performance Tracking Analyze medical utilization patterns, claims data, provider performance and programs performance and identify cost drivers and areas for improvement. Work with the different key stakeholders to identify requirements such as development of dashboards, reports, and insights that support UM strategies. Monitor and track key metrics such as LOA issuance rates, outlier detection trends, and cost savings achieved. Stakeholder Coordination Collaborate with other UM, Medical, PNM, and Operations teams to execute projects and align strategies. Provide regular updates to management on operational performance and project outcomes. Policy Execution & Compliance Implement UM policies related to utilization cost management and ensure adherence across operational workflows. Assist in the formulation and execution of policy changes to enhance cost efficiency without compromising care quality. Ensure compliance with regulatory requirements and internal guidelines. Risk Management & Quality Assurance Monitor patient outcomes to ensure that cost-control measures do not negatively impact healthcare quality. Identify and mitigate risks associated with high-cost cases and chronic disease management. Support UM leadership in implementing corrective actions when utilization patterns indicate potential inefficiencies or risks.