RN Leader, Utilization Management — Remote in Ohio

Buckeye Health Plan; Kentucky; On-site; USD 87,000 - 161,000; Full time

Job summary

Buckeye Health Plan seeks a clinical professional to lead the Medical Management/Health Services team in Ohio. The role focuses on overseeing Prior Authorization, Concurrent Review, and Retrospective Review to ensure appropriate member care.

In-person attendance is required a few times per year, with remote aspects available within Ohio. Requires RN licensure in Ohio and 5+ years of related experience; 2+ years of supervisory experience preferred.

Qualifications

• Graduate of an Accredited School of Nursing or Bachelor's degree with 5+ years of related experience.
• 2+ years supervisory experience preferred.
• Knowledge of utilization management principles preferred.

Responsibilities

• Manages prior authorization, concurrent review, and retrospective clinical review team.
• Reviews utilization management activities, costs, and forecast data for improvement.
• Develops, implements, and maintains UM policies and procedures.
• Reviews UM reports to identify trends and provide recommendations to senior leadership.
• Maintains knowledge of regulations and accreditation standards related to UM.
• Educates UM team and facilitates communication with members and providers.
• Leads and supports change within scope of responsibility.
• Onboarding, hiring, and training UM team members.

Skills

Utilization management

Leadership

Clinical review

Team management

Education

Bachelor's degree in Nursing

Graduate of an Accredited School of Nursing

Job description

Buckeye Health Plan seeks a clinical professional to lead the Medical Management/Health Services team in Ohio. The role focuses on overseeing Prior Authorization, Concurrent Review, and Retrospective Review to ensure appropriate member care.

In-person attendance is required a few times per year, with remote aspects available within Ohio. Requires RN licensure in Ohio and 5+ years of related experience; 2+ years of supervisory experience preferred.