Senior Utilization Management Data Analyst

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

This role is responsible for organizing, coordinating, and communicating Utilization Management (UM) business needs, including integration with internal application systems and the enterprise data warehouse. The position supports the development, implementation, and ongoing maintenance of UM data solutions, ensuring alignment with business objectives and regulatory requirements. Serving as a key liaison, this role provides subject matter expertise on UM data, promoting data integrity, accuracy, and effective information management across the organization. The position requires strong attention to detail and advanced technical aptitude to identify issues, analyze root causes, and implement effective solutions that enhance data quality and operational performance.

Responsibilities and Qualifications

• Coordinate and translate UM business needs into data and system requirements, ensuring alignment with enterprise applications and data warehouse structures
• Drives the development and sustainment of UM data solutions, ensuring compliance with operational and regulatory standards while owning the analysis and quality monitoring of data outputs.
• Act as a subject matter expert and liaison for UM data, driving data integrity, governance, and consistency across systems. Routinely monitors data outputs to Identify data discrepancies and system issues; develop and implement solutions to improve accuracy and performance
• Participates in various projects by delivering data-driven insights that support internal and external program development, cost and utilization trend analysis, and clinical management initiatives, applying strong business knowledge.
• Partner cross-functionally with IT, analytics, data science, and business teams to enhance data workflows and reporting capabilities.
• Accountable for maintaining technical documentation related to Utilization Management (UM) reporting requirements, ensuring accuracy, completeness, and alignment with regulatory and operational standards.
• Participate in User Acceptance Testing (UAT) for UM systems, validating that system changes meet defined business and technical requirements, particularly as they relate to UM operational and regulatory reporting.

Skills:

• Demonstrates strong communication skills, effectively and consistently engaging diverse audiences; clearly articulates UM data use cases and delivers high-quality, finished products internally and externally, with minimal supervision.
• Excels in organizing and managing competing priorities, multitasking in fast-paced environments, and quickly adapting to changing demands to consistently deliver on deadlines.
• Possess great attention to details along with strong technical aptitude to recognize issues along with problem-solving skills.
• Project management skills, ability to manage assigned projects with detailed project plans and methodologies, lead effective work teams, and create innovative solutions that meet or exceed established project objectives.
• Ability to identify operational and service problems, recommend and implement process enhancements, to increase efficiency and productivity.
• Uses Excel and data analysis tools to organize, review, and summarize operational data, including basic sorting, filtering, formatting, lookup/reference logic, and pivot tables to support UM compliance tracking, vendor reporting, and project coordination.
• Applies foundational data-structure knowledge to support quality checks and requirements gathering, including understanding fields, record-level detail, file layouts, naming conventions, missing values, duplicates, and how data should align across vendor submissions, internal reports, and compliance outputs.
• Reviews vendor data submissions and reporting logic with enough analytic fluency to ask effective follow-up questions, identify inconsistencies or gaps, and escalate potential issues before they affect final reporting, compliance deadlines, or deliverables.

Knowledge:

• This individual possesses knowledge of UM business processes and data and claims data, from both the perspective of internal and external with delegated UM vendor(s), along with strong data management skills to serve as data steward to deliver UM data needs.
• Knowledge of data processing terminology and concepts including high-level technical understanding of data technologies and how to apply cost benefit analysis techniques.
• Familiarity with basic database navigation and simple SQL concepts such as locating tables, understanding joins, filtering records, reviewing query outputs, and partnering with technical staff to validate that requested data can be produced accurately.

Experience:

• 5 years of experience in an analytical business environment, with a strong focus on operations data and information management, as well as research and analytical support.
• Advanced proficiency in PC applications, including Excel, Crystal Reports, Power BI, and various reporting and testing approaches.
• Knowledge of UM-specific health plan regulations preferred.
• Familiarity with business process modeling, requirements gathering, and project management methodologies.

Education and Certifications:

• Bachelor’s degree in business administration, health care administration, information systems or related field required or additional 4 years relevant experience.

Physical Demands:

• Sedentary work that involves significant periods of sitting, talking, hearing, and keying. Work environment includes typical office conditions.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.     And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.