Utilization Management SME - REMOTE

Job Summary
We are seeking an experienced and knowledgeable Subject Matter Expert (SME) / Advisor to provide expert guidance and strategic advice for multiple critical projects aimed at reducing Lab and Imaging cost of care for a Medicare Advantage health plan. The successful candidate will play a key advisory role in developing, implementing, and optimizing cost-saving strategies in the areas of laboratory and imaging services within the Medicare Advantage program. This individual will work closely with project teams, leadership, and external stakeholders to identify opportunities for cost reduction while maintaining high-quality care for plan members.  
 
Primary Responsibilities

• Strategic Advisory: Provide expert advice on reducing lab and imaging costs while ensuring compliance with Medicare Advantage regulations and guidelines.
• Data Analysis & Benchmarking: Analyze current spend trends for lab and imaging services, identifying high-cost areas and opportunities for improvement. Provide benchmarking against industry standards and best practices.
• Cost Optimization Strategies: Collaborate with cross-functional teams to design and implement cost-reduction strategies, including network optimization, utilization management, and contract negotiations with vendors.
• Stakeholder Collaboration: Work closely with leadership, clinicians, and operations teams to ensure alignment of cost-saving initiatives with the overall strategic goals of the health plan.
• Regulatory Compliance: Ensure that all cost-reduction strategies comply with Medicare Advantage policies, regulations, and best practices, avoiding potential risks or penalties.
• Market Research: Stay up-to-date on emerging trends, policies, and innovations in lab and imaging services within Medicare Advantage to advise on the most effective cost-saving approaches.
• Reporting & Communication: Prepare regular reports on the status and impact of cost-reduction initiatives, highlighting key performance metrics, savings, and areas for improvement. Present findings to senior leadership and other stakeholders.
• Process Improvement: Identify inefficiencies in current workflows and recommend process improvements to streamline operations, reduce waste, and improve cost management.
• Risk Management: Evaluate and mitigate risks associated with changes in lab and imaging service providers or utilization patterns.

 
Education and Experience

• Bachelor's degree in Healthcare Administration, Business, Public Health, or a related field; Master's degree preferred.
• Minimum of 7-10 years of experience in healthcare management, with specific expertise in Medicare Advantage programs.
• Proven experience in managing or advising on lab and imaging services cost optimization, utilization management, or network management.
• Strong understanding of healthcare billing, coding, and reimbursement processes, particularly in relation to Medicare Advantage.
• Experience with data analytics, financial modeling, and benchmarking in healthcare settings.
• Excellent communication, presentation, and interpersonal skills to effectively engage with diverse stakeholders.
• Strong problem-solving abilities and a strategic mindset.
• Ability to manage complex projects and deliver results within deadlines.
• Proficiency in Microsoft Office Suite (Excel, PowerPoint, Word), data visualization tools, and analytics platforms.
• Preferred: Certification in Healthcare Management (e.g., CHC, CHFM)
• Knowledge of Medicare Advantage risk adjustment, Star ratings, and quality metrics is a plus.
• Ability to work independently and as part of a collaborative team.
• Strong attention to detail and ability to manage multiple priorities.
• Willingness to travel, if necessary, to meet with stakeholders or attend meetings.