Clinical Utilization Management

To evaluate and monitor the utilization of medical services, procedures, tests, medications,referrals, and cost-effectiveness. Apply clinical expertise and analytical skills to uncover innovative strategies that more effectively address the needs of specific populations, enhancing outcomes, stakeholder contentment, and departmental productivity.

Clinical Benchmarking and Best Practices Analytics

• Oversee the collection and integration of clinical data from diverse sources, including electronic health records, patient outcomes, and operational metrics.
• Collaborate with IT teams to ensure data integrity and completeness.
• Utilize descriptive analytics to identify patterns, trends, and areas for improvement in clinical practices.
• Implement predictive analytics models to forecast clinical trends and recommend proactive interventions.
• Apply prescriptive analytics to recommend actionable strategies for enhancing clinical operations

Internal Utilization Management &Telemedicine Efficiency

• Implement measures to assess the outcomes of telemedicine visits, including patient outcomes, referral pattetn, prescritptions and follow-up care.
• Benchmark against peer groups that effectively measure and improve telemedicine outcomes.
• Monitor and establish a feedback loop for the medical team, encouraging open communication and continuous improvement.
• Ensures timely escalation of unresolved care coordination issues to the appropriate level.
• Proactively communicates with physicians to discuss opportunities identified related prescription rates, referrals, admissions and continued stay.

Partner Provider Collaboration

• Collaborate with partner providers in the utilization review process, ensuring that medical services are aligned with best practices and utilization guidelines.
• Establish a feedback loop for continuous improvement based on utilization review outcomes.
• Leverage behavioral analytics and data-driven insights to understand the patterns and trends in the behavior of partner providers.
• Identify opportunities for positive provider opportunities and interventions where necessary.
• Regularly analyze the performance of partner providers, considering key metrics such as patient outcomes, efficiency, and adherence to utilization guidelines.

Cost-effectiveness Analytics

• review processes, ensuring the efficient allocation of resources and identifying opportunities for cost savings without compromising quality.
• Participate in validating care pathways from commercial point of view and provide feedback to the medical team
• Work with key internal stakeholders, mainly the medical operation teams to collaborate on executing different projects.

• Data visualization tools and Analytical skills.
• Problem-solving Skills.
• Communication and presentation skills.

Bachelor's/Master's degree medical, healthcare management or healthcare informatics