Manager Health Services

Job Description

Job Description

Position Overview

The Health Services Manager serves as the cross-functional clinical and operational lead for Native Advantage’s Medicare Advantage plan. This role provides operational leadership for utilization management, care management, quality improvement, and the end-to-end appeals and grievances processes. The position supports and provides operational oversight to the Medical Director and collaborates closely with Compliance, Member Services, and the Utilization Management Committee to ensure timely, compliant, and member-centered decision-making.

Key Responsibilities

• Serve as cross-functional clinical and operational lead for a small Medicare Advantage plan, ensuring regulatory compliance, timely decision-making, and effective collaboration with Medical Directors, Utilization Management Committee, Compliance, and Member Services.
• Operationalize and oversee utilization management, including prior authorization, concurrent and retrospective review, and medical necessity determinations, in alignment with CMS requirements and plan policies.
• Develop and lead the care management program, including complex case management, care coordination, and transitions of care for high-risk members, to support the Quality Improvement Program and drive quality improvement initiatives.
• Manage the end-to-end appeals, grievances, and complaints processes, including Part C organization determinations, reconsiderations, related member communications, and oversight of Part D delegated services.
• Provide operational support and oversight to the Medical Director, coordinating clinical review workflows and ensuring efficient execution of physician-level responsibilities.
• Partner with Compliance and operational teams to maintain audit readiness and continuous improvement in clinical and member-facing processes.

Qualifications

• Current, unrestricted Registered Nurse (RN) license in Oklahoma (required).
• Minimum 5 years of progressive experience in Medicare Advantage or managed care, with direct involvement in utilization management, care management, quality improvement, and/or appeals and grievances.
• Strong working knowledge of CMS Medicare Advantage regulations related to medical necessity, utilization management, organization determinations/reconsiderations, and quality programs.
• Demonstrated ability to lead cross-functional teams, manage competing priorities, and operate effectively in a small-plan, highly regulated environment.

Required Skills & Competencies

• Strong clinical judgment combined with operational and regulatory acumen.
• Excellent collaboration, communication, and relationship-building skills across clinical and non-clinical teams.
• High integrity, attention to detail, and commitment to member-centered, compliant care.
• Proven ability to prioritize, organize, and deliver results in a fast-paced regulatory environment.