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Remote Insurance Utilization Review Jobs in Oklahoma

CSAA

Marketing Engagement Partner - Remote

Kansas, OK · Remote

Track and monitor Club marketing funding utilization to ensure compliance with Producer Agreements ... CSAA Insurance Group is an equal opportunity employer. #li-ml1 . The national average salary range ...

Chloeta

Management Analyst

Oklahoma City, OK · On-site +1

$35 - $40/hr

... utilization, and program performance. Supervisory Responsibilities : No Job Classification ... Remote / Virtual Travel: Travel up to 50% Compensation: This pay band reflects Chloeta's good faith ...

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Remote Insurance Utilization Review information

What is the difference between Remote Insurance Utilization Review vs Remote Claims Reviewer?

AspectRemote Insurance Utilization ReviewRemote Claims Reviewer
CredentialsTypically requires nursing or healthcare-related certifications, such as RN or licensed healthcare professionalUsually requires insurance or claims processing knowledge, sometimes with certifications like CPC or CPC-H
Work EnvironmentRemote, healthcare or insurance company settings, reviewing medical necessity and appropriateness of servicesRemote, insurance companies or third-party administrators, reviewing claims for accuracy and compliance
Industry UsageCommonly used in healthcare insurance to evaluate medical necessityUsed across insurance sectors to process and validate claims

Remote Insurance Utilization Review focuses on assessing the medical necessity of services, often requiring healthcare credentials. Remote Claims Reviewers handle claims processing and validation, emphasizing insurance knowledge. Both roles are remote and industry-specific but differ in their primary responsibilities and required qualifications.

How does a remote insurance utilization review professional collaborate with healthcare providers and insurance companies?

Remote insurance utilization review professionals regularly interact with healthcare providers to gather patient information, clarify treatment plans, and ensure that clinical documentation supports insurance requirements. They also communicate with insurance companies to advocate for patient care, provide necessary justifications, and resolve coverage issues. While the work is done remotely, collaboration typically occurs via secure email, phone calls, and virtual meetings, requiring strong communication and organizational skills to ensure timely and accurate exchange of information.

What are remote insurance utilization review jobs?

Remote insurance utilization review jobs involve evaluating medical records and treatment plans to determine whether healthcare services are medically necessary and covered by a patient’s insurance plan. Professionals in these roles, often nurses or other healthcare specialists, work from home and communicate with healthcare providers, insurance companies, and patients. Their main goal is to ensure that patients receive appropriate care while also helping insurance companies manage costs and comply with regulations.

What are the key skills and qualifications needed to thrive as a Remote Insurance Utilization Review Specialist, and why are they important?

To thrive as a Remote Insurance Utilization Review Specialist, you need a strong understanding of medical terminology, clinical guidelines, and insurance policies—usually supported by a nursing or health-related degree and relevant licensure. Familiarity with electronic medical record (EMR) systems, insurance claims platforms, and utilization review software is essential. Strong analytical skills, attention to detail, and effective written communication are crucial soft skills for this role. These competencies ensure accurate case evaluations, compliance with regulations, and clear communication between healthcare providers and insurers.
What are the most commonly searched types of Insurance Utilization Review jobs in Oklahoma? The most popular types of Insurance Utilization Review jobs in Oklahoma are:
What are popular job titles related to Remote Insurance Utilization Review jobs in Oklahoma? For Remote Insurance Utilization Review jobs in Oklahoma, the most frequently searched job titles are:
What job categories do people searching Remote Insurance Utilization Review jobs in Oklahoma look for? The top searched job categories for Remote Insurance Utilization Review jobs in Oklahoma are:
What cities in Oklahoma are hiring for Remote Insurance Utilization Review jobs? Cities in Oklahoma with the most Remote Insurance Utilization Review job openings:
Remote Insurance Utilization Review jobs near you
Manager, Utilization Management (51741)

Manager, Utilization Management (51741)

GLOBALHEALTH HOLDINGS LLC

Oklahoma City, OK • On-site, Remote

Full-time

Medical

Posted 27 days ago

Job description

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.

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