Milliman Utilization Management Jobs in Usa

Blue Cypress is seeking a Utility Management Services (UMS) Director to oversee our company’s utility management consulting services group. This position will work closely with our existing UMS staff in Atlanta, Seattle, and Cincinnati, seeking to expand work with current clients, win work with new clients, expand our services, and facilitate career development of staff. As an integral part of our business development and technical team, the UMS Director will oversee UMS staff, client projects, develop and maintain client relationships, and oversee business development activities. The ideal candidate has a minimum of 20 years of increasing responsibility and experience primarily as a utility management and/or engineering consultant at an A&E firm; public sector experience is also valued. This job posting is for Atlanta, but we would consider a candidate in the Seattle area as well. The successful candidate will have a strong professional network within either the Atlanta or Seattle metro area and a technical focus on water, wastewater, and/or stormwater systems. This candidate must have a successful track record of leadership, developing and maintaining client relationships, managing complex projects, delivering projects on time and on budget, leading business development activities, and managing a team. They should thrive in a fast-paced environment and exemplify Blue Cypress’s values: Collaboration, Strategic Development, and Improvement-Oriented Growth.

Responsibilities include:

• Provide specialized management consulting services in areas that may include: strategic planning, infrastructure management/asset management, operational optimization/lean processes, regulatory support, maintenance management, capital planning/forecasting, system planning, technology selection/on-boarding, data management/analytics/visualization, etc. More detailed related duties may include:
• Plan, design, and implement operations and maintenance optimization and capital planning and renewal strategies for water, wastewater, and/or stormwater for utilities.
• Design and oversee analyses on large infrastructure datasets, such as GIS, computerized maintenance management system (CMMS), customer information systems, condition assessment/inspection databases, capacity assessment/hydraulic modeling, etc.
• Perform services on-site as necessary to support client engagement
• Ensure project managers in the department successfully deliver projects on time and on budget by staying informed on projects, monitoring progress, and providing support to mitigate risk.
• Perform quality control and quality assurance reviews of deliverables in accordance with Blue Cypress policy, including project management reviews
• Maintain and grow client relationships and assess client needs with the goal of delivering tailored, cost effective, solutions. Oversee business development activities such as client engagement, proposal writing, and presentations
• Be accountable for UMS-related operations metrics such as bookings and revenue goals, utilization, workload management and resource allocation, accuracy of timesheets and expense reports, and other metrics as assigned
• Work in a fast-paced environment with oversight from the Owner. Take direction from and proactively communicate to multiple internal stakeholders including the COO and Marketing & Business Development Manager
• Lead internal strategic business planning for the UMS group and lead/direct internal strategic initiatives
• Develop business development strategies in collaboration with the Marketing & Business Development Manager and the Regional Directors
• Mentor early-, mid-, and senior-career staff including
• Giving timely, constructive feedback
• Being responsible for professional development planning
• Embody, maintain and promote Blue Cypress culture
• Implement and promote Blue Cypress policies, processes, and procedures.
• Oversee UMS internal operations
• Periodic travel required
• Perform other related duties as necessary or assigned

Minimum Qualifications

• Bachelors degree in Civil Engineering, Environmental Engineering, or a related technical discipline
• Minimum of 20 years of experience primarily as an engineering consultant in an Atlanta or Seattle A/E firm; public sector experience also valued. Focus on water, wastewater or stormwater systems
• Advanced proficiency in utility management and asset management consulting services
• Demonstrated positive personal brand developed with partners and clients identified by being a go-to resource
• Demonstrated strong people management skills with ability to strengthen and build team dynamics
• Ability to receive and act upon constructive feedback
• Demonstrated strong project management skills with ability to effectively manage collaborative teams with concurrent projects and deadlines
• Established network of contacts in utility field within the Southeastern or Pacific Northwest regions, particularly Atlanta- or Seattle-metro, including local engineering firms and utility clients
• Proven ability to establish and grow client base
• Strong written and verbal communication skills
• Enthusiasm, professionalism, creativity, and strong interpersonal skills
• Outstanding critical thinking skills
• Must be detail-oriented and able to prioritize, multitask, and organize complex projects
• Strong interest in local government and public agency operations and management, utility management, and asset management consulting services
• Ability to periodically travel to other Blue Cypress locations as well as utilities across the region or country

Preferred Qualifications

• Master’s degree in engineering, public administration, business administration, environmental science, or other technical graduate science degree
• Licensed professional engineer (PE) in the State of Georgia or Washington
• Experience in environmental regulatory space
• Certification in Asset Management
• Certified Project Management Professional (PMP)
• Experience or interest in growing into airport, transit, transportation, or other physical infrastructure intensive sectors

Required software proficiencies include:

• Microsoft Office applications (Excel, Word, Outlook, PowerPoint, OneNote, Sharepoint)

Preferred software proficiencies include:

• Microsoft specialized applications (Access, Power Query, PowerPivot, Visio, Project)
• Proficient in creating pivot tables, pivot charts, writing formulas (e.g., performing v-lookups) within Microsoft Excel
• Writing queries and joining tables within Microsoft Access or similar SQL environment
• Esri ArcGIS ArcMap and/or Pro and various extensions such as Spatial Analyst
• Esri Apps including Workforce, Survey123, Collector, etc.
• Understanding of industry software such as Trimble Cityworks, Central Square’s Lucity, Infor/Hansen, IBM Maximo, InfoAsset Planner, hydraulic and hydrological modeling, CCTV, FOG, Fleet, etc.
• Understanding of data warehouse and business intelligence tools such as Tableau, Qlik, Power BI, etc.

Supervisory Responsibilities:

• This position will include supervision of personnel.

Travel:

• There is potential travel up to 50%, consisting primarily of travel within the local Metropolitan Area (e.g. driving to client sites, attending meetings/conferences, etc.) with some travel to other Blue Cypress locations and to out of state clients.

Work Authorization

Applicants must be authorized to work for any employer in the U.S. We are unable to sponsor or take over sponsorship of an employment visa at this time.

Work Environment:

This is a hybrid position (in office/remote). We offer a telecommute option to work once a week from the office, with a minimum of 6 times per month at the office, and the remainder of the time to work from home. If desired, employees may work up to every day in the office instead of at home. During onboarding, new hires may be required to work more frequently in-person at the office. While in the office, the employee will normally work in a temperature-controlled office environment, with frequent exposure to electronic office equipment. Smoking and vaping shall be prohibited in all enclosed areas within the workplace.

Registered Nurse (RN) - Utilization Management

FT Day Shift (Hrs.: 8a-4:30p) - On-site

Newark, DE

ChristianaCare Hospital in Newark, DE, is seeking a Utilization Management Nurse (RN) with experience with insurance providers such as Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the Newark Hospital.

PRIMARY FUNCTION:

Responsible for ensuring the delivery of efficient and effective health care while evaluating the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provision of the applicable health benefits plan.

UTILIZATION MANAGEMENT

• Performs admission and concurrent review to identify medical necessity, level of care, and appropriateness of setting using established criteria and clinical guidelines within 24 hours of admission.
• Reviews the admission assessment and collaborates with primary nurse and other health care providers to ensure a multidisciplinary plan-of-care is in place to meet identified patient care needs and desired outcomes.
• Manages observation level of care and works with the attending physician and/or clinical provider caring for the patient to ensure observation status does not exceed 48 hours.
• Identifies system issues that serve as barriers to care.  Participates in the development and implementation of strategies to remove barriers and facilitate performance improvement measures.
• Monitors efficiencies in scheduling diagnostic procedures and coordination of treatments to facilitate the achievement of effective clinical, fiscal, quality, and patient satisfaction goals.
• Reports information generated from the utilization management referral process for LOS data and physician profile database.
• Collaborates with the unit medical director and/or physician advisor to facilitate achievement of clinical, quality, financial, and patient satisfaction goals.
• Notifies physician when a patient does not meet criteria for acute care hospitalization and pursues documentation to justify continued stay within 24 hours.
• Collaborates with the Physician Advisor to facilitate the achievement of clinical, quality, financial, and patient satisfaction goals.
• Presents “Letters of Non-Coverage (LON) to patients and/or families when the acute stay is no longer necessary (Third Party and/or Medicare).
• Communicates and secures continued stay authorization with Managed Care Organizations.
• Tracks all carve-outs and submits reason codes for data entry.
• Serves as a resource to nursing and ancillary staff, providing education on utilization review processes as needed.
• Trends potential barriers to patient advancement through the system intervene assertively and appropriately when necessary.
• Provides On-call support for the Transfer Center to evaluate medical necessity and appropriateness when a request is obtained from an outside facility for patient transfer to ChristianaCare
• Identifies the need for the patient to be evaluated by other members of the health care team and takes appropriate action to facilitate.
• ED UM works closely with ED providers to review medical necessity and/or collaborate with ED CM for discharge planning, as appropriate.
• Actively participates in department operational planning work groups.

Education & Experience Requirements:

• DE RN licensure or compact state RN licensure. 
• Bachelor’s degree in nursing Required.
• Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting. critical care experience is required.
• Minimum 3 years of Utilization Management experience required.
• Prior experience working with insurance providers is valuable.
• Completes a minimum of 8 continuing education credits (CEU’S) per year in Utilization and/or Case Management.

PHYSICAL DEMANDS:

Ability to ambulate within the hospital setting (walking, stairs, etc.).  Occasional sitting, standing, and lifting loads of 5-10 pounds.  Ability to utilize computer equipment/programs. Ability to sit or stand at a computer workstation and proficiently utilize computer equipment/programs for long periods of time.

WORKING CONDITIONS:

Occasional exposure to Office materials (i.e., White Out, Toner, etc.)

Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.

Summary:

The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
• Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
• Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
• Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary’s member’s health care for behavioral health care management.
• Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
• Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines.
• Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.
• Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up.
• Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
• Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate. 
• Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
• Must be able to take after hour calls to meet business requirements as needed.

Job Requirements:

Education/Skills

• Graduate of an accredited school of vocational nursing or equivalent required
• Associate’s (ADN) or Bachelor’s (BSN) in Nursing preferred

Experience

• 3 – 5 years of nursing experience preferred
• Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
• General computer knowledge and capability to use computers required

Licenses, Registrations, or Certifications

• LVN license in the state of employment or compact required
• RN license in state of employment or compact preferred

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time

SUMMARY:

• Palm Springs, CA
• Salary: $130,000 – $160,000 per year
• Hospital Setting

The individual in this position has overall responsibility for hospital utilization management, transition management and operational management of the Case Management Department in order to promote effective utilization of hospital resources, timely and accurate revenue cycle processes, denial prevention, safe and timely patient throughput, and compliance with all state and federal regulations related to case management services.

This position integrates national standards for case management scope of services including:

• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to physicians, patients, families and caregivers

The individual’s responsibilities include the following activities: a) manage department operations to assure effective throughput and reimbursement for services provided, b) lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, c) ensure medical necessity and revenue cycle processes are completed accurately and in compliance with CMS regulations and Tenet policy, d) ensure timely and effective patient transition and planning to support efficient patient throughput, e) implement and monitor processes to prevent payer disputes, f) develop and provide physician education and feedback on hospital utilization, g) participate in management of post-acute provider network, h) ensure compliance with state and federal regulations and TJC accreditation standards, and i) other duties as assigned.

QUALIFICATIONS:

Required: Bachelor’s degree in business, Nursing or Health Care Administration for RN or master's in social work for MSW.

Preferred: MSN, MBA, MSW or MHA.

Required: 3 years of acute hospital case management or healthcare leadership experience.

Preferred: 5 years of acute hospital case management leadership multi-site experience

Required: Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified, or registered to practice profession as required by law or regulation in state of practice or policy. Active RN or LCSW/LMSW license for state(s) covered.

Preferred: Accredited Case Manager (ACM)

Text Nancy at 915-305-7508

Send your resume to

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Immediate need for a talented Registered Nurse – Case Manager/ Utilization Manager. This is a 03+ months contract opportunity with long-term potential and is located in San Francisco, CA (Onsite). Please review the job description below and contact me ASAP if you are interested.

Job ID: 26-01370

Pay Range: $80- $95/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Perform daily pre-admission, admission, and concurrent utilization reviews
• Determine appropriate levels of care using clinical guidelines and policies
• Coordinate inpatient discharge planning and transitions of care
• Participate in multidisciplinary rounds with physicians and care teams
• Communicate discharge plans with patients, families, and external providers
• Arrange transfers, post-acute services, and obtain authorizations as needed
• Ensure continuity of care through accurate documentation and follow-up
• Maintain compliance with federal, state, and institutional regulations
• Educate care teams on utilization and care coordination processes

Key Requirements and Technology Experience:

• Skills-Inpatient Case Management & Discharge Planning
• Utilization Management / Utilization Review (UM/UR)
• Acute hospital experience (inpatient setting)
• Knowledge of CMS, DMHC, NCQA, TJC, HIPAA, EMTALA
• Strong interdisciplinary communication and care coordination
• Ability to independently manage inpatient caseloads
• Healthcare benefit interpretation and authorization coordination
• Graduate of an accredited school of nursing
• Diploma or Associate Degree in Nursing (ADN) required
• Active California RN License (Required)
• BLS Certification (Required)
• Minimum 2 years of experience in:
• Utilization Management
• Case Management
• Discharge Planning
• Recent acute inpatient hospital experience
• Ability to work rotating schedules and every other weekend
• Comfortable working in a Labor/Management Partnership environment
• Bachelor’s degree in Nursing or healthcare-related field
• Master’s degree in Case Management

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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Program Manager – Electric Utilities (90% Remote | Kentucky)

Coalesce Management Consulting (CMC) is seeking an experienced Program Manager to lead a portfolio of utility projects (~$200M+) for a major client. This is a 5-year engagement offering strong leadership exposure and long-term stability.

Key Responsibilities

• Support and help in leading Utility Company’s project portfolio
• Oversee project pipeline, reporting, and stakeholder communication
• Ensure compliance with regulatory and safety standards
• Drive performance, resource planning, and delivery excellence

Requirements

• Program Management experience within Electric Utilities
• Experience managing large-scale project portfolios
• Strong leadership and stakeholder management skills
• Willingness to travel ~1-2x/month as needed

What’s on Offer

• 90% remote (Kentucky-based)
• Travel fully expensed
• Competitive pay + retention bonus
• Annual development allowance

For a confidential discussion, please contact

Summary:

The Registered Nurse Clinical Care Coordinator is responsible for establishing, coordinating, and maintaining the process to increase patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum for the ED. The RN Clinical Care Coordinator collaborates with the patient and/or family, multidisciplinary team, physicians, community partners, and payers to ensure the patient’s progress and level of care are appropriately determined and evaluates or screens patients entering the CHRISTUS Health System for medical necessity. The RN Clinical Care Coordinator will collaborate with relevant providers and partners to determine the appropriate patient class and level of care of patients entering the CHRISTUS Health system to ensure the appropriate utilization of resources and maximize appropriate reimbursement opportunities. The RN Clinical Care Coordinator will utilize problem-solving and customer service skills to determine the best course of action for the patient, the physician, and the hospital by working closely with facility House Supervisors, referring physicians, ED, and inpatient staff to ensure the effective and efficient admission/placement of every patient. This job requires the full understanding and active participation in fulfilling the Mission of CHRISTUS Health. It is expected that the associate demonstrates behavior consistent with the Core Values. The associate shall support CHRISTUS Health’s strategic plan and the goals and direction of their Performance Improvement Plan (PIP).

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Reviews clinical information for patients upon entry into the health system to determine appropriate placement and patient class to maximize appropriate hospital reimbursement and positively manage length of stay.
• Coordinates with onsite partner providers (LTACH, Inpt Rehab) to review requests for facility services and ensure appropriate use of outpatient hospital resources for (their patients) including scheduling coordination and appropriate escort by sending provider.
• Review all ED patients identified by the treating physician as requiring admission to the hospital to ensure appropriate patient class and resource utilization.
• Educates hospital and ED providers on levels of care, resource utilization, payor practices, and documentation. Escalates to Physician Advisor or CMO when discrepancies are present.
• Performs the initial clinical medical necessity review utilizing evidence-based criteria and enters into the medical record for the receiving CM team.
• Utilizes high risk screening criteria to make appropriate community and post-ED referrals.
• Initiates prior authorization process when indicated for post-ED referrals and services.
• Escalates to physician advisor when unable to resolve discrepancies with the attending physician.
• Manages high-use patients and works to find alternatives for care to frequent ED visits.
• Plans for discharges from the ED for patients who do not require admission to include arranging for Home Health, DME, placement, and community resources as they relate to social determinants of health.
• Provides patient and family education and counseling about existing health problem related care.
• Anticipates barriers/variances to the delivery of care and intervenes as necessary.
• Intervenes with physicians and ancillary departments concerning clinical and utilization issues to ensure optimal patient outcomes.
• Coordinates and facilitates patient progression throughout the continuum.
• Collaborates with all members of the interdisciplinary team to facilitate appropriate care coordination and care delivery.

Job Requirements:

Education/Skills

• Graduate of an accredited school of nursing required

Experience

• 2 years of experience in Case Management and/or Utilization Management required

Licenses, Registrations, or Certifications

• RN License in the state of employment required
• BLS required

Work Schedule:

MULTIPLE SHIFTS AVAILABLE

Work Type:

Part Time