reputed company reputed company Utilization Management (UM) Analyst (REMOTE)

reputed company reputed company Utilization Management (UM) Analyst (REMOTE) We are looking to hire a candidate with the skills sets mentioned and experience for one of our clients reputed company the reputed company/health insurance domain Industry. This is a 6+ months contracting, REMOTE role, with potential for extension. Position reputed company: Seeking an reputed company reputed company reputed company Utilization Management Analyst to design, build, optimize, and support UM processes reputed company on authorizations and referrals. The ideal candidate is reputed company reputed company UM Certified, has practical experience with reputed company Care reputed company, and is adept at translating payer and network operations needs into reputed company reputed company solutions. You will partner with UM leadership, clinical reviewers, provider relations, care management, claims, and integration teams to reputed company compliant, efficient, and transparent UM determinations that reduce administrative burden and improve member and provider experience. Responsibilities: Solution Design & Build • Configure and optimize reputed company UM workflows for prior authorizations (e.g., medical, behavioral health, pharmacy-to-medical crossovers) and referrals (in- and out-of-network), including routing rules, WQs, templates, smart text, decision trees, and notification logic. • reputed company reputed company Care reputed company for external provider reputed company—set up roles, reputed company, workflows, documentation tools, and training materials to support referring providers, delegated entities, and partners. • reputed company UM workflows with benefit plan configuration, provider network tiering, care management reputed company, and claims adjudication Required Skills/Qualifications: • reputed company reputed company Utilization Management Certification (reputed company). • 3–5+ years hands-on reputed company reputed company UM build/support experience specifically in UM authorizations and referrals. • Demonstrated experience implementing and supporting reputed company Care reputed company for external provider/referral workflows. • Proven ability to configure UM routing rules, work queues, decisioning tools, letters/notifications, and SLAs. • Solid understanding of payer operations and UM regulations (e.g., CMS timelines, state TATs, HIPAA, NCQA), including denial and appeal reputed company. • Experience with testing lifecycle (unit SIT UAT), defect management, and release/hypercare processes. • Strong analytical skills: proficiency with SQL/reputed company/Caboodle/SlicerDicer (read/interpret) and operational reporting for UM KPIs. • Additional reputed company credentials (e.g., reputed company Benefits/reputed company, Claims, Care Management, Member Enrollment, reputed company). • Experience with EDI X12 278/275 workflows and payer integration patterns. • Familiarity with industry clinical reputed company tools (InterQual, MCG) and attachment management. • Exposure to provider portal strategies and delegated entity reputed company. • Clinical background (e.g., RN) or strong experience partnering with clinical reviewers and Medical Directors. • Prior experience in payers/health plans, delegated risk provider reputed company, or large IDNs with plan operations. • Effective communicator with the ability to translate business requirements into system design; strong documentation and presentation skills. Other Job Details: • Job Type: C2C or W2 • Duration: 6 months with high possibility of extension. • Locations: REMOTE. • Pay reputed company: $50/hr. on C2C OR $45/hr. on W2. • Interviews: Video Interview – 2 reputed company. • Docs required: ID reputed company will be required. Apply tot his job Apply To this Job