Experience: 8+ Years
Visa: EAD, TN, E2, L2, (No H1B & OPT)
Role Summary:
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.
Required skills:
• Epic Tapestry Utilization Management Certification (active).
• 3–5+ years hands-on Epic Tapestry UM build/support experience specifically in UM authorizations and referrals.
• Demonstrated experience implementing and supporting Tapestry Care Link for external provider/referral workflows.
• Proven ability to configure UM routing rules, workqueues, decisioning tools, letters/notifications, and SLAs.
• Solid understanding of payer operations and UM regulations (e.g., CMS timelines, state TATs, HIPAA, NCQA), including denial and appeal pathways.
• Experience with testing lifecycle (unit → SIT → UAT), defect management, and release/hypercare processes. • Strong analytical skills; proficiency with SQL/Clarity/Caboodle/SlicerDicer (read/interpret) and operational reporting for UM KPIs.
• Effective communicator with the ability to translate business requirements into system design; strong documentation and presentation skills.
Never miss an opportunity! Create an alert based on the job you applied for.
