Utilization Management Clinical Admin Operations Liaison

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We’re looking for the next generation of health care leaders.

At Ameri Health Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. Ameri Health Caritas is seeking talented, passionate individuals to join our team.

Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, Ameri Health Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

As part of the Utilization Management (UM) Administrative team, the UM Clinical Administrative Operations Liaison is responsible for the coordination and ongoing monitoring of UM program objectives, including support of performance improvement projects for service and clinical activities, integrating the quality improvement and efficiencies into all UM department activities. Supports the UM Administrative and Operations Team activities using clinical knowledge to provide insight for processes, policies, and reporting.

Supports the overall operation of UM programs that meet or exceed applicable State, Federal and NCQA standards Under the direction of the Manager UM Administrative Operations and Audit, supports UM through policy writing and updates, development of program documents and updates, development of processes, report development and validation of reports prior to submission. Provides support and clinical insight as needed for external audits and accreditation surveys.

Represents UM at Quality meetings to present changes, documents and work-plan required items.

• Responsible for supporting successful development and evaluation of an annual UM work plan and program description by collaborating with corporate and market UM leadership and other areas throughout the organization, as necessary.
• Request reports both standing and adhoc, supports validation of the data upon report completion, Identifies, resolves, and/or escalates problematic UM areas to UM leadership, which may impact the department’s ability to achieve annual goals.
• Using clinical knowledge and knowledge of UM review process to identify errors and risks with audit files, reporting and communicate any identified issues or risks to UM Admin and Ops manager and plan UM leadership.
• Works with the accreditation team to review accreditation standards to ensure Corporate UM documents are updated appropriately, training material developed/shared with team leaders, and communicated to the UM Admin team
• Participates in the development, implementation and maintenance of UM policies and procedures.
• Works professionally and efficiently with all functional areas in meeting organizational and departmental UM goals.
• Collaborates with each Market to ensure policies are created and /or updated in accordance with State, Federal, regulatory and accrediting body’s standard requirements.
• Ensures timely…