United States onlyYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: Directs the utilization management team to ensure the appropriate application of policy procedures and processes to help support best member outcomes. Oversees and manages Utilization Operations specific to the daily operations of Utilization Management including timeliness, quality and performance outcomes, provider interactions and experience and associated regulatory and/or compliance measures. Oversees the end-to-end management of authorization reconciliation and post claim authorization functions, ensuring seamless coordination between authorization processes, claims reconciliation, and provider case resolution. This role focuses on optimizing operational workflows, enhancing data accuracy, and driving efficiency to support timely and compliant claims outcomes.
- Leads utilization management team on performance, improvement, and career growth path considerations
- Leads utilization management team policies and procedures to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards
- Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program
- Leads process improvements for the utilization management team to achieve cost-effective healthcare results and presents to senior leadership team
- Establishes policies and procedures that incorporate best practices and ensure effective utilization reviews of members
- Develops utilization management strategies and influences decisions by providing recommendations that align to organizational objectives
- Responsible for components of the department’s budget while collaborating inter-departmentally with senior leadership
- Executes the overall strategy for onboarding, hiring, and training new utilization management team members to ensure adequate training and high quality-care to improve member and provider experience and ensure compliance
- Leads and champions change within scope of responsibility
- Partner closely with claims and clinical and non-clinical Utilization Management (UM) team members to align processes and improve end-to-end handling of authorization related claim issues
- Direct the resolution of authorization-related denials and post claim escalations tied to authorization issues, ensuring timely and accurate outcomes
- Provide strategic leadership and oversight for provider claim disputes, reconsiderations related to authorizations and/or medical necessity
Education/Experience: Requires a Bachelor's degree and 7+ years of related experience, including prior management experience. Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position. 4+ years management experience preferred. Expert knowledge of industry regulations, policies, and standards preferred. Knowledge of claims issues related to authorizations highly preferred.
License/Certification:
- RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
