Clinical Utilization Management & Analytics Specialist

The Clinical Utilization Management and Analytics Specialist performs senior-level clinical and analytic work to improve the value of TRS health programs. The position may be filled by a registered nurse, physician, or pharmacist with substantial healthcare analytics and utilization management experience. Using data from utilization management outcomes, prior authorization, provider quality, and claims, the position identifies avoidable or low-value spending and develops clinically appropriate opportunities to improve efficiency and quality of health care delivery.

The position oversees the health plan administrator’s utilization management operations and works with internal stakeholders, consulting firms and benefit vendors to reduce waste while protecting quality, safety, timely access, and medically necessary care.

WHAT YOU WILL DO

Utilization Management Oversight

• Monitors and improves the health plan administrator’s utilization management operations, including prior authorization, concurrent and retrospective review, case management, appeals, and transitions of care.
• Designs custom utilization management requirements, clinical protocols, and performance expectations, and assesses adherence to established criteria and industry standards.
• Evaluates vendor performance and recommends actions to reduce waste, improve affordability and outcomes, and preserve access to medically necessary care.
• Serves as a primary clinical and analytic resource for utilization management contract oversight, including prior authorization, medical necessity criteria, peer-to-peer review, site-of-care optimization, exception management, and escalated clinical issues. Clinical Program Development and Implementation
• Collaborates with TRS leadership, consultants, and health plan administrators to design and implement custom utilization management requirements and clinical programs.
• Collaborates with health plan administrators to operationalize approved utilization management changes and ensure consistent implementation.
• Evaluates proposed utilization management policies, clinical criteria, and program enhancements for alignment with TRS objectives.
• Develops evidence-based initiatives that reduce unnecessary high-cost care and promote appropriate lower-cost settings and less-invasive, high-quality alternatives.
• Assists with developing contract requirements, performance standards, and clinical program specifications during procurements and contract amendments.
• Coordinates implementation activities related to new utilization management initiatives, clinical programs, and regulatory changes. Clinical Analysis and Strategic Support
• Analyzes utilization management, prior authorization, site-of-care, claims, outcomes, and provider data to identify cost drivers, avoidable utilization, low-value care, variation, clinically appropriate alternatives, and opportunities to improve quality and total cost of care.
• Evaluates proposed programs for their effects on quality, access, site-of-care, member experience, and total cost.
• Develops reports, dashboards, business cases, and recommendations that quantify opportunities and measure cost, utilization, quality, and outcomes.
• Provides clinical expertise for policy development, vendor management activities, audits, procurements, and special projects. Performs related work as assigned.