Job Details
Bringing prior experience as a nurse, this Solutions SME serves as the bridge between the clients and our customer operations teams for implementation, production support, development, configuration, quality assurance, product documentation, and compliance.
This role also provides product design direction throughout the customer lifecycle to ensure a consistent customer experience while maintaining the integrity of the solutions for the customer.
The ideal candidate will have experience processing cases and working in production support with a ticketing system (ServiceNow, JIRA, Zendesk, Salesforce etc).
Responsibilities:
Support client implementations and production support clinical software solutions for Utilization Management, Care Management, and Medical Appeals as a subject matter expert to ensure the success of our clients.
Define product content, workflows and service level agreements required to meet client requirements, as well as the regulatory and accreditation requirements of the industry.
Work closely with internal release management, development, IT/Operations, compliance and other departments for timely implementation of new platform feature enhancements, continued product support and product innovation.
Document and maintain use case requirements to test accurate system functionality testing.
Conduct end to end module testing for clinical solutions to ensure accurate functionality prior to releasing to internal models and/or new revision releases.
Identify problems within the clinical solutions and communicate them through established change management process.
Provide solutions approvals as required by the release management process.
Perform other duties as assigned by the Manager.
Required Qualifications:
- Bachelor Degree in Nursing (BSN) with active RN license
- Minimum of 1 year or Product Owner or Product Manager experience
- Three-Five (3-5) years of experience within health plan within one or more of the following areas Utilization Management, Care Management, Medical Appeals and Grievances.
- Strong understanding of the healthcare industry and experience working with/knowledge of CMS, NCQA, URAC and other health plan accreditation and regulatory compliance.
- Previous experience with leveraging technology solutions to support health plan or PBM operations, supporting software solution implementations, and defining user requirements.
Preferred Qualifications:
- Experience leveraging evidence-based guidelines (e.g. MCG, InterQual) for making medical necessity determinations.
- Experience with performing case management assessments and developing care plans to improve member outcomes.
- Ability to adapt to competing demands, take on new responsibilities, and adjust plans to meet shifting priorities.
- Ability to maintain a positive, constructive approach to problem solving internally and during customer interactions with focus on timely and accurate issue resolution.
- Previous experience translating business requirements into system configuration.
- Previous Scrum based product development experience in SaaS environment, including hands-on active participation in production support, implementations, and projects.
- Previous experience performing detailed market, competitive, customer needs and software product feature analysis.
- Previous experience defining, building, and executing test cases.
- Experience presenting and communicating with all levels of organizations.
- Excellent written, verbal communication and interpersonal skills.
- Proficient with JIRA, Word, Power Point, Excel, Visio and Document Management.
Additional Requirements:
- Ability to work on EST Eastern Time Zone.
- Occasional travel to support client projects.
- Ability to work remotely and travel to Florida office if needed.
- Ability to sit for extended periods of time.