Director, Utilization Management

Centene Corporation•Northampton, MO

1d•Remote

About The Position

You 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. This is a remote position with a preference to work in CST. This role will have oversight clinical and non-clinical UM Appeals teams with a focus in behavioral health- experience in this area is highly preferred. RN/Clinical Licensure is highly preferred. 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 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 manages others in a matrixed/cross functional environment with tight timeframes and strict deadlines Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards

Requirements

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.

Nice To Haves

4+ years management experience preferred.
Expert knowledge of industry regulations, policies, and standards preferred.
RN/Clinical Licensure is highly preferred.
experience in behavioral health is highly preferred

Responsibilities

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
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 manages others in a matrixed/cross functional environment with tight timeframes and strict deadlines
Leads and champions change within scope of responsibility
Performs other duties as assigned
Complies with all policies and standards