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Remote Utilization Review Manager Jobs in Oklahoma

Harris

Remote Care Management - CMA

Kansas, OK · Remote

Chart Review: 8 min Outreach Attempts: 6 min Actual Call: 11 min Care Coordination: 9 min Total ... Our program offers a customized model of remote care services that blends Chronic Care Management ...

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Remote Utilization Review Manager information

What is a remote utilization review manager?

A Remote Utilization Review Manager is a healthcare professional responsible for overseeing the review of medical services and determining the necessity, appropriateness, and efficiency of those services from a remote location. They ensure that healthcare providers comply with guidelines and that patients receive appropriate care without unnecessary procedures. These managers work with clinical teams, insurance companies, and regulatory agencies to optimize patient outcomes and manage healthcare costs. Working remotely allows them to perform these duties using digital health records and telecommunication tools.

What are the key skills and qualifications needed to thrive as a remote utilization review manager?

To thrive as a Remote Utilization Review Manager, you need expertise in healthcare management, case review, and regulatory compliance, typically supported by a nursing degree (RN or BSN) and relevant certifications such as CCM or URAC. Familiarity with utilization management software, electronic health records (EHRs), and payer systems is essential. Strong analytical thinking, attention to detail, and excellent communication skills help navigate complex cases and collaborate with clinical teams and insurers. These skills ensure effective resource utilization, regulatory adherence, and optimal patient outcomes in a remote healthcare environment.

What are some common challenges faced by a remote utilization review manager, and how can they be addressed?

A Remote Utilization Review Manager often encounters challenges such as maintaining effective communication with clinical teams, ensuring timely and accurate reviews, and staying updated with changing regulations and payer requirements. To address these, it's important to leverage secure collaborative platforms, establish clear workflows, and participate in ongoing training. Building strong relationships with team members and regularly reviewing protocols also help in overcoming remote work hurdles and ensuring compliance and efficiency.

What is the difference between Remote Utilization Review Manager vs Remote Utilization Review Nurse?

AspectRemote Utilization Review ManagerRemote Utilization Review Nurse
CredentialsTypically requires a nursing license, certifications like URAC or AAPC, and management experienceLicensed Registered Nurse (RN) with utilization review certification often preferred
Work EnvironmentOversees review teams, manages processes, and ensures compliance remotelyPerforms case reviews, assesses medical necessity, and documents findings remotely
Employer & Industry UsageHealth insurance companies, third-party administrators, healthcare organizations

The Remote Utilization Review Manager focuses on overseeing review teams and managing processes, while the Remote Utilization Review Nurse conducts case assessments and medical necessity reviews. Both roles require nursing credentials and are integral to healthcare utilization management, but differ in responsibilities and leadership levels.

What are the most commonly searched types of Remote Utilization Review jobs in Oklahoma?

The most popular types of Remote Utilization Review jobs in Oklahoma are:

What are popular job titles related to Remote Utilization Review Manager jobs in Oklahoma?

For Remote Utilization Review Manager jobs in Oklahoma, the most frequently searched job titles are:

What job categories do people searching Remote Utilization Review Manager jobs in Oklahoma look for?

The top searched job categories for Remote Utilization Review Manager jobs in Oklahoma are:

What cities in Oklahoma are hiring for Remote Utilization Review Manager jobs?

Cities in Oklahoma with the most Remote Utilization Review Manager job openings:

Remote Utilization Review Manager jobs near you

Molecular Diagnostics Medicare Medical Director - Palmetto GBA

Ourhrconnect

Kansas, OK • On-site, Remote

$309K - $413K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 3 days ago

New

Key responsibilities

  • Oversees medical staff, analyzes utilization data, and researches emerging molecular technologies.

  • Develops, writes, and revises medical policies to ensure compliance and support Medicare coverage decisions.

  • Supports operations through case review on medical and regulatory matters, and develops claim adjudication criteria requiring medical judgment.

Job description


Summary
 Why should you join the BlueCross BlueShield of South Carolina family of companies?
Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Position Purpose:
The Molecular Diagnostics Medicare Medical Director at Palmetto GBA oversees medical staff, analyzes utilization data, research emerging molecular technologies, and serves as a resource for providers and internal teams on policy issues. The role also includes developing, writing, and revising medical policies to ensure compliance and support Medicare coverage decisions.
Description
 

Logistics: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies.

Location: This position is full-time (40-hours/week) Monday-Friday working REMOTE in the United States or ONSITE at our GPC location at 17 Technology Circle, Columbia, SC.

Sponsorship: This position is not eligible for sponsorship now or in the future.

What You'll Do:

  • Supports operations in the form of case review on both medical and regulatory matters. Develops claim adjudication criteria for situations requiring medical judgment. Provides input on issues and operational policies, processes, and procedures.

  • Educates staff and medical community on various aspects of medical policy and program administration.

  • May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies. Develops external relationships with the medical community and serves as liaison between these entities and the contractors.

  • Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.

  • Conducts research into new or controversial medical procedures and technology.

To Qualify For This Position, You'll Need The Following:

  • Required Education: Doctorate degree Medical Doctor (MD) with current active license to practice medicine.

  • Required License and Certificate: Active state medical license and current board certification in a recognized specialty.

  • Required Work Experience: 5 years post graduate experience in direct patient care.

  • Required Skills and Abilities: Excellent verbal and written communication skills. Excellent customer service, organizational, and presentation skills.Proficiency in spelling, punctuation, and grammar. Ability to persuade, negotiate, or influence others. Ability to work as a team member as well as a leader. Knowledge of medical and utilization review techniques.

  • Required Software: Microsoft Office Suite.

We Prefer That You Have The Following:

  • Molecular Genetic Pathology fellowship training.

  • Medicare experience.

  • Experience interpreting medical evidence.

  • Scientific training/Research experience with publication history in Molecular Diagnostics.

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

  • Subsidized health plans, dental and vision coverage

  • 401k retirement savings plan with company match

  • Life Insurance

  • Paid Time Off (PTO)

  • On-site cafeterias and fitness centers in major locations

  • Education Assistance

  • Service Recognition

  • National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers, and contribute their unique abilities to the growth of our company.

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.

Pay Range Information:

Range Minimum
$206,011.00

Range Midpoint
$309,767.00

Range Maximum
$413,523.00

Pay Transparency Statement:

Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilitiesand protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.comor call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's moreinformation.

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