General Summary: Provides assistance in completing comprehensive quantitative as well as qualitative analysis to support Medical Management strategic decision making. Responsible for the development or coordinating the development and maintenance of the Care Management Platform, within Health and Network Management. The development process includes defining requirements, writing detailed specifications, assisting with programming, testing, debugging, implementing, & documenting application programs, and conveying new knowledge to colleagues. Provide production support for business applications and resolve problems and issues quickly. Provides accurate and timely regulatory report submission to entities including Centers for Medicare & Medicaid Services (CMS), MI Department of Insurance and Financial Services (DIFS), National Association of Insurance Commissioners (NAIC), and National Committee for Quality Assurance (NCQA). Principal Duties and Responsibilities:
- Conduct analysis for Medical Management using all available data sources. Prepare and deliver well-organized reports to reflect the findings, analytic methods and implications. Identify opportunities to drive improvement. Ensure report accuracy and timeliness.
- Complete all assigned divisional regulatory and accreditation reporting with precision, accuracy, and by established deadlines, aligned with standards under CMS, DIFS, and NCQA.
- Initiate the analysis of, and ensure adequate evaluation of, Care Management system impacts. Serve as the system experts and liaison with IT departments.
- Prepare recommendations for enhancements to the Care Management Platform, with prioritization based on the impact to compliance activities, cost savings, efficiency and satisfaction.
- Develop and execute a comprehensive test plans to ensure program accuracy.
- Make approved configuration updates to the Care Management Platform. Ensure Change Control processes are followed and that impacts to system performance (rules), interfaces and outputs (reports/letters) are well understood. Make required technical, testing, policy and desk level procedure documentation updates.
- Prepare report and letter specifications. Develop reports and letters using Crystal Reports or other report writing tool (or work with IT to develop).d
- Identify opportunities on an ongoing basis that would promote greater efficiencies in process and technology within Medical Management.
- Ensure continuous interaction with IT to maintain data integrity and to assure coordination between IT efforts and Medical Management's needs, in order to expedite responses and resolution of system problems/issues.
- Monitor project scheduling and completion. Perform ongoing quality review checks to ensure a quality implementation.
- Provide support to HNM trainers, as needed.
- Work with external vendors to evaluate, compare, and demo software packages. Ensure software being considered fits within HAP's technical arena. Make recommendations to management based on evaluation.
- Perform other related duties as assigned.
Education/Experience Required:
- Bachelor's Degree in Business and/or Health Care Administration, Economics, Biostatistics, Epidemiology, Finance or related field is required. In lieu of a Bachelor's Degree, 5 years of relevant experience is acceptable.
- At least two (2) years of progressive analytical experience in a healthcare or managed care/insurance related setting with specific exposure to one or more of the following: utilization management, appeals & grievance, case management, disease management, patient/member data.
- Demonstrated experience with data interpretation, analysis, and reporting; clinical and financial data; key performance indicators as it relates to medical cost data.
- Demonstrated project management experience in running cross-team projects.
Experience Preferred:
- Experience with SQL and report writing tools.
- Experience in relational database concepts.
- Experience with Care Management platforms.
Certifications/Licensures Required:
- Within one year of hire, complete Epic Tapestry Fundamentals, Integrated Build & Tapestry Utilization Management Administration courses and achieve certification.
Skills and Abilities:
- Ability to perform as a Team Player, as well as independently, and with minimal supervision.
- Ability to develop and maintain professional contacts with HAP's internal customers and outside application vendors.
- Technical knowledge, analytical skill, reliability and initiative required to implement quality systems.
- Ability to collect and prepare data for written and/or oral presentations and to present the data effectively to all levels of management.
- Ability to multitask and thrive in an ever changing environment.
- Ability to speak and communicate effectively, either in person and electronically, with all levels in the organization.
- Ability to read, write, and interpret documents and correspondence.
- Ability to analyze data reports and identify opportunities for improvement.
- Knowledge of business principles and functions in order to understand the procedures and needs of customers and to make appropriate process improvements.
- A high level of human relations skills in order to be effective in working with people of varied skills, backgrounds, and personalities at various levels throughout the organization.
Additional Information
- Organization: HAP (Health Alliance Plan)
- Department: Program Optimization
- Henry Ford Health Location: HAP (Health Alliance Plan)
- Shift: Day Job
- Union Code: Not Applicable
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Henry Ford Health System
Apr 22, 2025