Manager, Utilization Management

Centene Corporation • Remote-OK, OK

1d • $87,000 - $161,300 • Remote

About The Position

The Manager, Utilization Management manages a team responsible for prior authorization, concurrent review, retrospective clinical review, and/or appeals, ensuring appropriate care for members. The role also manages utilization management issues involving member care and provider interactions and facilitates utilization management operations.

This is a remote position. Candidates must reside in Oklahoma and hold an active RN license. The role includes participation in weekend on-call coverage. The position requires healthcare leadership, utilization management, and managed care experience, along with computer proficiency and strong communication, customer service, attention to detail, organizational, management, and time-management skills.

The manager reviews utilization management activities, operations, costs, forecasts, and reports to identify trends and improvement opportunities, and provides recommendations and updates to senior leadership. The role develops, implements, and maintains compliance with utilization management policies, procedures, and guidelines; supports team communications and education; coaches team members on quality and performance standards; and assists with onboarding, hiring, and training. The manager also maintains knowledge of applicable processes, regulations, accreditation standards, and industry best practices, and champions change within their scope of responsibility.

Requirements

• Graduate of an accredited school of nursing or a bachelor's degree.
• At least 5 years of related experience.
• Active RN (Registered Nurse) state licensure and/or compact state licensure.
• Reside in Oklahoma.
• Healthcare leadership, utilization management, and managed care experience.
• Computer proficiency, including proficiency in Microsoft Office applications.
• Excellent communication and customer service skills.
• Strong attention to detail, organizational and management abilities, and effective time-management skills.

Nice To Haves

• At least 2 years of supervisory experience.
• Knowledge of utilization management principles.

Responsibilities

• Manage prior authorization, concurrent review, appeals, and/or retrospective clinical review teams and ensure compliance with applicable guidelines, policies, and procedures.
• Review and analyze utilization management activities, operations, costs, and forecasted data to identify improvement opportunities aligned with goals and objectives.
• Develop, implement, and maintain compliance with utilization management policies and procedures.
• Review utilization management reports, identify trends and improvement areas, and provide recommendations to senior leadership.
• Maintain knowledge of processes, regulations, accreditation standards, and industry best practices related to utilization management.
• Educate and provide resources to the utilization management team on key initiatives and facilitate ongoing communication among the team, members, and providers.
• Work with senior management to develop and implement utilization management policies, procedures, and guidelines that support appropriate and effective healthcare service use.
• Provide updates and insights to the utilization management senior management team on team goals and objectives.
• Coach and guide the utilization management team to support adherence to quality and performance standards.
• Assist utilization management senior leadership with onboarding, hiring, and training team members.
• Lead and champion change within the scope of responsibility.
• Perform other duties as assigned.
• Comply with all policies and standards.
• Participate in weekend on-call coverage.

Benefits

• Health insurance
• 401(k) and stock purchase plans
• Tuition reimbursement
• Paid time off and holidays
• Flexible approach to work, including remote, hybrid, field, or office work schedules
• Competitive pay

What This Job Offers

• Job Type: Full-time
• Career Level: Manager