Manager, Utilization Management

Centene • Rosedale, NY

227d • $85,300 - $158,100

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. Must have a New York RN license. Position Purpose: Manages Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Manages utilization management issues related to member care, provider interactions, and facilitates operations within utilization management. Manages prior authorization, concurrent review, and retrospective clinical review team and ensures compliance with applicable guidelines, policies, and procedures. Reviews and analyzes utilization management activities, operations, costs, and forecasted data to identify areas for improvement within utilization management (UM) to align to goals and objectives. Develops, implements, and maintains compliance with utilization management policies and procedures. Reviews utilization management reports to identify trends and areas of improvement and provide recommendations to senior leadership. Maintains knowledge of processes, regulations, accreditation standards, and industry best practices related to utilization management. Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers. Works with the senior management team to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services. Works with utilization management senior management team to provide updates and insights on team goals and objectives. Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards. Assists utilization management senior leadership with onboarding, hiring, and training utilization management team members. Leads and champions change within scope of responsibility. Performs other duties as assigned. Complies with all policies and standards.

Requirements

• Graduate of an Accredited School of Nursing or Bachelor's degree.
• 5+ years of related experience.
• 2+ years supervisory experience preferred.
• Knowledge of utilization management principles preferred.
• RN - Registered Nurse - State Licensure and/or Compact State Licensure required.

Responsibilities

• Manages Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team.
• Ensures appropriate care to members.
• Manages utilization management issues related to member care and provider interactions.
• Facilitates operations within utilization management.
• Ensures compliance with applicable guidelines, policies, and procedures.
• Reviews and analyzes utilization management activities, operations, costs, and forecasted data.
• Identifies areas for improvement within utilization management to align to goals and objectives.
• Develops, implements, and maintains compliance with utilization management policies and procedures.
• Reviews utilization management reports to identify trends and areas of improvement.
• Provides recommendations to senior leadership.
• Maintains knowledge of processes, regulations, accreditation standards, and industry best practices.
• Educates and provides resources for utilization management team.
• Facilitates ongoing communication between utilization management team, members, and providers.
• Works with senior management to develop and implement UM policies, procedures, and guidelines.
• Provides updates and insights on team goals and objectives.
• Provides coaching and guidance to ensure adherence to quality and performance standards.
• Assists with onboarding, hiring, and training of utilization management team members.
• Leads and champions change within scope of responsibility.
• Performs other duties as assigned.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible approach to work with remote, hybrid, field or office work schedules.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree