Remote Utilization Review Manager Jobs in Edmond, OK

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 direction of the Supervisor, Heath Services Coordination, provides administrative support for utilization review, health education and care management. This includes data entry, communication with members, providers, and vendors for education and information gathering. 

ESSENTIAL JOB FUNCTIONS:

• Following Medicare/Medicaid Timelines for Notification to Provider/Members to meet department goals and requirements.
• Verbal and/or written outreach to members and/or providers to provide updates on referral request status, reasoning behind decisions, and provide accurate information.
• Daily Mail fulfillment – faxes to provide notification to provider or member of decisions,
• Coordination of services for members, including community resources and collaboration with assigned case manager
• Develop and maintain resources related to the department.
• Support departmental initiatives.
• Identify and report process improvement opportunities.
• Manage and document member and provider calls.
• Enter authorization requests in the medical management systems.
• Process member notifications
• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs other duties as assigned.

EDUCATION AND EXPERIENCE:

• High School diploma or equivalent and two years of data entry experience in an administrative support position required.
• Experience working with medical records preferred.
• Experience working in managed care or utilization management environment preferred.

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong attention to detail
• Excellent communication skills, Clear and effective written and verbal
• Organization and time management skills, including ability to prioritize tasks.
• Strong working knowledge of Microsoft Word, Visio, Excel and Power Point.
• Strategic and Analytic thinking, Lean Six Sigma Green belt or Black belt- preferred.
• Ability to work independently and with a group.
• Self-motivated
• Excellent customer service skills
• Demonstrated knowledge of managing the use of a SharePoint site or equivalent application

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:

N/A

SUPERVISORY RESPONSIBILITY:

N/A

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.