Business Analyst – Utilization Management

About the role

We are seeking a Business Analyst with strong analytical and technical skills to support our Utilization Management (UM) team. You will work closely with clinical staff, IT, and leadership to drive data‑based decisions that improve cost‑containment and operational efficiency.

Key responsibilities

• Analyze utilization trends, claims, and pharmacy data to identify cost‑containment opportunities.
• Document, review, and enhance UM processes such as intake, concurrent review, and appeals.
• Define business requirements for IT solutions and conduct user acceptance testing (UAT) for UM software.
• Ensure UM processes comply with state, federal, and accreditation regulations.
• Act as a liaison between clinical staff (nurses, medical directors) and IT/leadership.

Required profile

• 3‑5+ years of experience in utilization management, care management, or managed‑care settings.
• Bachelor’s degree in Healthcare Administration, Nursing, or a related field.
• RN or LPN license is highly preferred for clinical data interpretation.
• Deep understanding of healthcare coding (ICD‑10, CPT), claims processing, and insurance regulations.

Required skills

• Strong SQL proficiency for data extraction and manipulation.
• Experience with data‑visualization tools such as Tableau or Power BI.
• Familiarity with electronic health record (EHR/EMR) systems.
• Advanced Excel and SAS for data analysis.
• Workflow modeling using Visio and reporting platforms.