Specialist, Utilization Management
TranscarentAbout this role
The Specialist, Utilization Management provides operational support and subject matter expertise to ensure the effectiveness and continuous improvement of Accolade's Utilization Management program. This role supports program execution by monitoring vendor process requirements, managing day-to-day program operations while identifying opportunities for process optimization and facilitating cross-functional collaboration to meet operational deliverables and business objectives. The Specialist, Utilization Management builds strong working relationships across Provider Services, external vendor partners (including AHH), and internal clinical and service operations teams to ensure seamless program integration and execution. This function is critical to Accolade’s ability to create and maintain trust in the quality of our services and dedication to continuous improvement with our customers and their consultant partners.
A day in the life…
- Support the evolution of Accolade’s UM program by identifying improvement opportunities.
- Monitor vendor performance against contractual SLAs, escalating gaps and collaborating on corrective action plans to ensure prior authorization/pre-certification delivery meets operational goals.
- Ensure adherence to UM policies and procedures across internal teams and vendor partners through training support, process monitoring, and issue resolution.
- Research and support resolution of client, member, and provider escalations related to UM determinations and processes, coordinating across internal teams and vendor partners to ensure timely, compliant, and member-focused outcomes.
- Facilitate issue resolution with health plan partners, vendors, and provider services team, ensuring timely response to operational complexities and client/member/provider or ecosystem partner inquiries.
- Serve as a key liaison between Accolade operations and AHH, managing day-to-day communication, escalations, and workflow coordination.
- Collaborate with cross-functional teams to support implementation of new processes and system enhancements.
- Partner with implementation team as a UM subject matter expert during new customer onboarding, providing guidance on program setup, criteria configuration, and workflow design.
- PES_Utilization Management Sharepoint folder/file structure, manage permissions and support colleagues in navigating the repository. Identify and implement continouous improvements, as applicable.
- Support internal and vendor related audit planning and preparation meetings including: Audit Kick-Off, Status Meetings, Call Finalization Meetings, Mock Audit, Audit Day and Post-Audit Follow-Up.
What we are looking for…
- Bachelors’ Degree or an equivalent combination of education/experience.
- 2+ years of relevant experience in utilization management operations, prior authorization coordination, UM program support, or healthcare operations.
- Experience working with external vendors, health plans, or third-party administrators in a UM or provider services capacity preferred
- Working knowledge of utilization management principles, prior authorization processes, and medical necessity review workflows
- Excellent analytical, problem solving, communication, presentation and conflict resolution skills.
- Strong research and analytical skills with ability to synthesize complex information and identify trends.
- Demonstrated ability to work independently, produce high quality deliverables and identify project delivery risks.
- Ability to work in an environment with changing priorities and embrace change.
- Continuous process improvement mindset.
- Experience interacting with external stakeholders.
- Proficiency in SmartSheets, Microsoft Word/Excel and PowerPoint.
Who we are
Transcarent is the One Place for Health and Careᵀᴹ, bringing medical, pharmacy, and point solutions together with the WayFindingᵀᴹ experience, the first and only generative AI-powered health and care platform for health consumers. Our WayFinding experience, paired with transparent and consumer-driven pharmacy care, 2nd.MD expert medical opinions, and virtual primary care, works seamlessly with comprehensive Care Experiences – Cancer Care, Surgery Care, and Weight Health – to support people with all of their health needs, simple or serious. More than 1,700 employers and health plans rely on us to provide information, guidance, and care, empowering health consumers with more choice, an experience they love, access to higher-quality care, and lower costs for 21 million Members. For more information, visit transcarent.com, and follow us on LinkedIn.
At Transcarent, our values guide everything we do:
- People First: We prioritize our Members, clients, and each other in every decision
- Care: Every decision starts with improving health and care for our Members
- Resilience: We push boundaries and take the uncharted path to change an industry
- Results: We take ownership, solve with speed, and deliver for our people and each other
- Humble and Human: We lead with humility, bring fun to tough moments, and go further together
Total Rewards
Individual compensation packages are based on a few different factors unique to each candidate, including primary work location and an evaluation of a candidate’s skills, experience, market demands, and internal equity.
Salary is just one component of Transcarent's total package. All regular employees are also eligible for the corporate bonus program or a sales incentive (target included in OTE) as well as stock options.
Our benefits and perks programs include, but are not limited to:
- Competitive medical, dental, and vision coverage
- Competitive 401(k) Plan with a generous company match
- Flexible Time Off/Paid Time Off, 13 paid holidays
- Protection Plans including Life Insurance, Disability Insurance, and Supplemental Insurance
- Mental Health and Wellness benefits
Transcarent is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out!
Research shows that candidates from underrepresented backgrounds often don’t apply unless they meet 100% of the job criteria. While we have worked to consolidate the minimum qualifications for each role, we aren’t looking for someone who checks each box on a page; we’re looking for active learners and people who care about disrupting the current health and care with their unique experiences.