Utilization Management (UM) Quality Assurance Analyst

Role description

Job Summary

The Utilization Management (UM) Quality Assurance Analyst is responsible for supporting quality improvement initiatives by conducting comprehensive audits, analyzing operational processes, identifying trends and opportunities for improvement, and ensuring compliance with utilization management policies and procedures. This role plays a critical part in maintaining the accuracy, consistency, and quality of UM reviews, documentation, and member interactions while supporting operational excellence and regulatory compliance.

The QA Analyst collaborates with leadership and operations teams to evaluate performance, provide actionable insights, develop educational materials, support system implementations, and contribute to continuous process improvement initiatives.

Key Responsibilities

Quality Assurance & Auditing

Perform quality assurance audits on completed prospective, concurrent, and retrospective utilization management reviews involving inpatient, outpatient, ambulatory, and ancillary services.

Evaluate accuracy, completeness, timeliness, and compliance of UM documentation and decision-making processes.

Conduct quality audits of member and provider calls to ensure adherence to policies, procedures, benefit plans, regulatory requirements, and customer service standards.

Verify the accuracy, consistency, and integrity of operational data and quality reports.

Identify audit findings, trends, risks, and opportunities for process improvement.

Auditing the nurses that processes appeals and grievances as well

Analysis & Reporting

Research, analyze, and evaluate data from multiple sources to identify discrepancies, trends, and potential operational issues.

Assist in monitoring quality initiatives, outcomes, metrics, and objectives to ensure performance goals are achieved.

Prepare reports, presentations, and other materials to communicate audit results and recommendations to management.

Support root cause analysis activities and recommend corrective and preventive actions.

Education & Training

Provides recommendation related to, but not limited to, the following:

Utilization Management policies and procedures

Clinical documentation standards

Benefit interpretation

Regulatory and compliance requirements

Quality improvement initiatives

Assist in the creation of user guides, training manuals, and process documentation.

Process Improvement & Project Support

Collaborate with leadership to identify operational challenges and recommend innovative solutions.

Support change management initiatives by assisting with planning, organizing, and controlling project activities.

Participate in User Acceptance Testing (UAT), system enhancements, and implementation projects as needed.

Assist in developing business requirements documentation and workflow improvement recommendations.

Support process redesign efforts to improve efficiency, accuracy, and quality outcomes.

Collaboration & Stakeholder Support

Partner with operations teams to validate report content, audit results, and quality findings.

Maintain effective communication with internal stakeholders and leadership regarding quality trends and performance improvement opportunities.

Maintain comprehensive knowledge of business operations, products, programs, organizational structure, and utilization management processes.

Additional Responsibilities

Perform other duties and special projects as assigned.

Support departmental and organizational objectives through ongoing quality improvement efforts.

Required Qualifications

Education

Bachelor's degree in Healthcare Administration, Nursing, Business Administration, Health Information Management, or related field preferred.

Equivalent combination of education and experience may be considered.

Experience

Minimum of 2 years of experience in U.S. Healthcare, UM account, quality background great with emphasis on:

Utilization Management (UM)

Medical Management Operations

Care Management or Managed Care environments

Preferred Experience

Quality Assurance (QA)

Experience auditing utilization management reviews and clinical documentation.

Experience in managed care, health plans, or third-party administration environments.

Experience supporting process improvement or operational quality initiatives.

Preferred Systems Knowledge

HealthEdge HRCM

GuidingCare

JIRA

Other utilization management platforms and workflow systems

Required Skills, Knowledge, and Abilities (SKA)

USRN License

Strong analytical and problem-solving capabilities.

Excellent verbal and written communication skills with the ability to communicate complex concepts clearly.

Strong organizational and planning skills with the ability to manage multiple priorities.

High attention to detail and commitment to accuracy.

Advanced proficiency in Microsoft Office applications, including:

Excel

Word

PowerPoint

Outlook

Ability to independently evaluate data and identify trends, gaps, and opportunities for improvement.

Ability to work both independently and collaboratively in a team environment.

Strong interpersonal skills and ability to interact effectively with employees, leaders, and clients at all organizational levels.

Flexibility and adaptability in a fast-paced and changing environment.

Ability to create and maintain business requirements documents, training materials, and procedural guides.

Understanding of quality assurance methodologies, audit principles, and continuous improvement practices.

Knowledge of utilization management workflows, healthcare benefits, and regulatory requirements.

Skills

Appian, Behavioral Health, Benefits Administration, Care Management, Claims Management, Clinical Documentation Improvement, Healthcare Systems, Microsoft Office, Registered Nurse, Stakeholder Management, Utilization Management

About UST

UST is a global digital transformation solutions provider. For more than 20 years, UST has worked side by side with the world’s best companies to make a real impact through transformation. Powered by technology, inspired by people and led by purpose, UST partners with their clients from design to operation. With deep domain expertise and a future-proof philosophy, UST embeds innovation and agility into their clients’ organizations. With over 30,000 employees in 30 countries, UST builds for boundless impact - touching billions of lives in the process.