Manager, Utilization Management (51741)

GLOBALHEALTH HOLDINGS LLC•Oklahoma City, OK

12d•Remote

About The Position

This position, under the guidance of the Vice President, Health Services is responsible for the operational oversight of the Utilization Management department. This includes tracking and trending of utilization data, development and update of policy and procedures, regulatory reporting and supervisory staff. The position also may include collaboration with internal teams and external providers.

Requirements

Current Oklahoma state RN license
Experience in Managed Care, Case Management and Concurrent Review
Previous experience in a supervisory role
Ability to communicate, both orally and written, and manage complex working relationships.
Excellent organizational, leadership, problem-solving, and decision-making skills.
Knowledge of Microsoft software programs including Word, Excel, PowerPoint and Power BI
Knowledge of quality improvement and utilization management

Nice To Haves

CPHQ, CPUR and previous insurance experience preferred

Responsibilities

Accountable for the functions of the Utilization Management department.
Develops and oversees policies and procedures, regulatory reporting and clinical practice guidelines.
Integrates quality improvement activities within utilization management.
Communicates regularly with employees through participation in regular staff meetings to share information appropriate to their job functions and development.
Serves as a resource to both lines of business in relation to Utilization Management.
Plays an active role in both internal and external committees along with contract delegated responsibilities.
Collaborates with network facilities to improve concurrent and discharge plans for our members.
Performs retrospective review for the claims department.
Assists in providing information for the appeals department.
Provides information to reinsurance for members pending transplantation.
Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.