Manager, Utilization Management (51741)

WHO WE ARE: 

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.

WHO YOU ARE:                                                                                                                       
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.

ESSENTIAL DUTIES AND RESPONSBILITIES:                                                                                

• 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.

EDUCATION AND EXPERIENCE:                                                                                                      

• Current Oklahoma state RN license
• Experience in Managed Care, Case Management and Concurrent Review
• Previous experience in a supervisory role
• CPHQ, CPUR and previous insurance experience preferred

KNOWLEDGE, SKILLS AND ABILITIES:                                                                                           

• 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

WORK ENVIRONMENT:                                                                                                                    

Current work environment is remote, however, some state exclusions apply.

Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies.

TRAVEL:                                                                                                                                            

Travel may be required for this position

SUPERVISORY RESPONSIBILITY:                                                                                                   

This position is in a supervisory role over Utilization Management leadership and staff

OTHER DUTIES:                                                                                                                                

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.