Manager, Utilization Management

Position Purpose: Manages Prior Authorization, Concurrent Review, Retrospective Review Clinical Review and/or Appeals team to ensure appropriate care to members. Manages utilization management issues related to member care, provider interactions, and facilitates operations within utilization management.

Key Details: This is a remote position, but candidates must reside in Oklahoma and hold an active RN license. The ideal candidate must be willing to participate in weekend on-call coverage and have experience in healthcare leadership, utilization management, and managed care. Candidates should be computer-savvy and proficient in Microsoft Office applications, with excellent communication and customer service skills. Strong attention to detail, organizational and management abilities, and effective time management skills are also essential for success in this role.

• Manages prior authorization, concurrent review, appeals, and/or retrospective clinical review team and ensures compliance with applicable guidelines, policies, and procedures
• Reviews and analyzes utilization management activities, operations, costs, and forecasted data to identify areas for improvement within utilization management (UM) to align to goals and objectives
• Develops, implements, and maintains compliance with utilization management policies and procedures
• Reviews utilization management reports to identify trends and areas of improvement and provide recommendations to senior leadership
• Maintains knowledge of processes, regulations, accreditation standards, and industry best practices related to utilization management
• Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers
• Works with the senior management team to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services
• Works with utilization management senior management team to provide updates and insights on team goals and objectives
• Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards
• Assists utilization management senior leadership with onboarding, hiring, and training utilization management team members
• Leads and champions change within scope of responsibility
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 5+ years of related experience.

2+ years supervisory experience preferred. Knowledge of utilization management principles preferred.

License/Certification

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required

Pay Range: $87,000.00 - $161,300.00 per year