Manager, Utilization Management

Centene Corporation•Remote-OH, OH

4d•$87,000 - $161,300•Remote

About The Position

Centene is seeking a Manager, Utilization Management to join their Medical Management/Health Services team. This role is part of the Buckeye Health Plan, Ohio Medicaid Line of Business, on the Concurrent Review Team. The position offers a flexible approach to work with remote options for candidates residing in Ohio. The Manager will oversee clinical review teams for Prior Authorization, Concurrent Review, and Retrospective Review, ensuring appropriate care for members and managing utilization management issues. This role involves analyzing operations, developing policies, educating the team, and collaborating with senior leadership to improve healthcare service utilization.

Requirements

Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 5+ years of related experience.
Candidates must reside in Ohio and hold an active RN Ohio license.
RN - Registered Nurse - State Licensure and/or Compact State Licensure required

Nice To Haves

2+ years supervisory experience preferred.
Knowledge of utilization management principles preferred.

Responsibilities

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