Healthcare analyst h1.location_city

Infosys Helix is seeking a Product Manager- Healthcare Clinical Lead for this growing team. The Clinical Lead oversees day‑to‑day operations of utilization management, clinical reviews, service authorization processes, and care management functions for the health plan. This role provides clinical expertise, ensures regulatory compliance, supports staff development, and drives appropriate, high‑quality care across the continuum. Key ResponsibilitiesUtilization Review & Clinical Review OversightConduct and oversee utilization reviews (prospective, concurrent, and retrospective) using evidence‑based criteria such as InterQual, MCG, CMS, and state guidelines.Perform clinical reviews of inpatient, outpatient, specialty, and ancillary services to determine medical necessity, level of care, and appropriateness.Support escalation and collaboration with Medical Directors for cases requiring physician review or adverse determinations.Ensure UM decision‑making complies with federal/state regulations, CMS requirements, NCQA/URAC standards, and timeliness expectations.Provide coaching to staff on documentation quality, criteria selection, and clinical justification.Service Authorization ManagementOversee the intake, triage, and review of service authorization requests (e.g., DME, home health, specialty services, behavioral health, advanced imaging).Ensure timely processing of authorizations within regulatory and contractual turnaround times (TATs).Review complex cases requiring clinical expertise and determine approval, modification, or need for medical director review.Monitor volume trends, authorization patterns, and provider issues to identify process improvements.Care Management IntegrationSupport transitions of care, coordination between UM and CM, and continuity across inpatient and outpatient settings.Participate in interdisciplinary rounds addressing high-risk, complex, or high-cost cases.Provide guidance to Care Managers on clinical issues impacting utilization, level of care, or benefit coverage.Collaborate with Care Management to identify members requiring engagement in case, disease, or population health programs.Quality, Compliance & AccreditationEnsure compliance with CMS, state Medicaid, DOI, and accreditation standards related to UM/CM (NCQA, URAC).Conduct documentation audits and support corrective actions to maintain audit readiness.Assist in developing, updating, and implementing UM and CM policies, workflows, and clinical guidelines.Participate in regulatory audits, readiness reviews, and internal quality committees.Operational Leadership & Staff SupportServe as a subject matter expert for clinical reviews, UM criteria, and service authorization workflows.Provide coaching, training, onboarding, and daily support to nurses, UM coordinators, and CM staff.Review cases for quality, accuracy, completeness, and compliance with organizational standards.Manage workload distribution, address barriers, and support issue resolution in real time.Provider & Cross‑Functional CollaborationCollaborate with providers on clinical documentation requirements, UM criteria, and decision rationales.Work with network providers to reduce unnecessary utilization and facilitate timely transitions of care.Partner with internal teams (Pharmacy, Behavioral Health, CM, Claims) to ensure seamless operations and problem resolution.Data & Performance MonitoringMonitor UM metrics including: Concurrent review timelinessAppeals and overturn ratesAuthorization turnaround timesLength of stay and readmission trendsHigh-utilization outliersUse analytics to identify trends, resource gaps, and opportunities to optimize utilization and member outcomes.Core CompetenciesClinical decision‑making & critical thinkingKnowledge of UM standards & clinical criteriaOperational rigor & regulatory complianceCommunication with members and providersCoaching, mentoring, and team leadershipWorkflow optimization & problem-solvingData-driven decision-makingCollaboration across multidisciplinary teamsRequired QualificationsThe candidate must be located within commuting distance of Tempe, AZ or be willing to relocate to this area. This position may require travel in the US. Bachelor’s degree or foreign equivalent required from an accredited institution. Will also consider three years of progressive experience in the specialty in lieu of every year of Education. 7 Yrs of Domain experience (Healthcare).5 yrs of clinical experience in utilization management, care management, or clinical review roles within a health plan, hospital, or integrated delivery system.Active, unrestricted RN license (or clinical licensure appropriate for UM, e.g., LPN in some markets, LCSW for integrated BH programs).Strong understanding of InterQual/MCG criteria, medical necessity reviews, and authorization processes.Knowledge of federal and state UM regulations, CMS guidelines, NCQA/URAC standards, and HIPAA.Excellent clinical judgment, communication, and documentation skills. Preferred QualificationsCertification in Case Management or Utilization Management (CCM, ACM-RN, CPUR, CPHM).Experience with Medicare Advantage, Medicaid Managed Care, or Commercial health plans.Familiarity with UM and CM platforms (e.g., GuidingCare, MHK, HealthEdge, TruCare, CaseTrakker).Experience in provider relations, audit support, or process improvement initiatives. Along with competitive pay, as a full-time Infosys employee you are also eligible for the following benefits:Medical/Dental/Vision/Life Insurance.Long-term/Short-term Disability.Health and Dependent Care Reimbursement Accounts.Insurance (Accident, Critical Illness, Hospital Indemnity, Legal).(k) plan and contributions dependent on salary level.Paid holidays plus Paid Time Off.The job entails sitting as well as working at a computer for extended periods of time. Should be able to communicate by telephone, email or face to face. Travel may be required as per the job requirements. Infosys provides equal employment opportunities to applicants and employees without regard to race; color; sex; gender identity; sexual orientation; religious practices and observances; national origin; pregnancy, childbirth, or related medical conditions; status as a protected veteran or spouse/family member of a protected veteran; or disability.