Tapestry UM Analyst

Role Type: Tapestry UM Analyst

Duration : 3 months

Telecommute : Yes

Description:

We are seeking an experienced Epic Tapestry Utilization Management Analyst to design, build, optimize, and support UM processes focused on authorizations and referrals. The ideal candidate is Epic Tapestry UM Certified, has practical experience with Tapestry Care Link, and is adept at translating payer and network operations needs into scalable Epic solutions. You will partner with UM leadership, clinical reviewers, provider relations, care management, claims, and integration teams to enable compliant, efficient, and transparent UM determinations that reduce administrative burden and improve member and provider experience.

Key Responsibilities Solution Design & Build

• Configure and optimize Tapestry UM workflows for prior authorizations (e.g., medical, behavioral health, pharmacy-to-medical crossovers) and referrals (in- and out-of-network), including routing rules, WQs, templates, smart text, decision trees, and notification logic.
• Leverage Tapestry Care Link for external provider access set up roles, security, workflows, documentation tools, and training materials to support referring providers, delegated entities, and partners.
• Align UM workflows with benefit plan configuration, provider network tiering, care management touchpoints, and claims adjudication

Summary:

• The candidate must have an active Epic Tapestry Utilization Management Certification, with 3 5+ years of hands-on experience in building and supporting Epic Tapestry UM systems, specifically focused on UM authorizations and referrals.
• They should demonstrate experience in implementing and supporting Tapestry Care Link for external provider and referral workflows.
• The ideal candidate will have proven abilities in configuring UM routing rules, workqueues, decision-making tools, letters, notifications, and SLAs.
• Additionally, a solid understanding of payer operations and UM regulations, including CMS timelines, state TATs, HIPAA, NCQA, and pathways for denial and appeal, is essential.
• Experience in the entire testing lifecycle from unit testing to SIT, UAT, defect management, and release/hypercare processes is required. The candidate should possess strong analytical skills and be proficient in SQL/Clarity/Caboodle/SlicerDicer (read/interpret) and operational reporting for UM KPIs.
• Effective communication skills are crucial, including the ability to translate business requirements into system designs and strong documentation and presentation capabilities.
• Additional Epic credentials, such as Tapestry Benefits/Contracts, Claims, Care Management, Member Enrollment, and Security, are highly desirable.
• Experience with EDI X12 278/275 workflows and payer integration patterns, familiarity with industry clinical criteria tools such as InterQual and MCG, and experience in attachment management are valuable assets.
• Exposure to provider portal strategies and oversight of delegated entities, a clinical background (e.g., RN) or significant experience partnering with clinical reviewers and Medical Directors, and prior experience in payers/health plans, delegated risk provider groups, or large Integrated Delivery Networks (IDNs) with plan operations would be beneficial.