Centene-posted 8 months ago
$73,800 - $132,700/Yr
Full-time • Mid Level
Buford, GA
Ambulatory Health Care Services

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. Position Purpose: Supervises the behavioral health (BH) utilization review clinicians to ensure appropriate care for members and supervises day-to-day activities of BH utilization management team. Monitors behavioral health (BH) utilization review clinicians and ensures compliance with applicable guidelines. Monitors and tracks UM BH resources to ensure adherence to performance, quality, and efficiency standards. Works with BH utilization management team to resolve complex BH care member issues related to BH. Maintains knowledge of regulations, accreditation standards, and industry best practices related to BH utilization management. Works with BH utilization management team and senior management to identify opportunities for process and quality improvements within utilization management. Educates and provides resources for BH utilization management team on key initiatives and to facilitate on-going communication between BH utilization management team, members, and providers. Works with the BH senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services. Evaluates BH utilization management team performance and provides feedback regarding performance, goals, and career milestones. Provides coaching and guidance to the BH utilization management team for optimal performance management and provides counseling and corrective action when required. Assists with onboarding, hiring, and training BH utilization management team members. Attends company meetings in absence of people leader. Acts as primary contact for escalated calls/issues that require research or special handling. Leads and manage others in a matrixed/cross functional environment. Leads and champions change within scope of responsibility. Presents information and responds to questions from peers, leaders and internal/external customers. Performs other duties as assigned. Complies with all policies and standards.

  • Supervises the behavioral health (BH) utilization review clinicians to ensure appropriate care for members.
  • Supervises day-to-day activities of BH utilization management team.
  • Monitors behavioral health (BH) utilization review clinicians and ensures compliance with applicable guidelines.
  • Monitors and tracks UM BH resources to ensure adherence to performance, quality, and efficiency standards.
  • Works with BH utilization management team to resolve complex BH care member issues related to BH.
  • Maintains knowledge of regulations, accreditation standards, and industry best practices related to BH utilization management.
  • Works with BH utilization management team and senior management to identify opportunities for process and quality improvements within utilization management.
  • Educates and provides resources for BH utilization management team on key initiatives.
  • Facilitates ongoing communication between BH utilization management team, members, and providers.
  • Develops and implements UM policies, procedures, and guidelines with BH senior management.
  • Evaluates BH utilization management team performance and provides feedback regarding performance, goals, and career milestones.
  • Provides coaching and guidance to the BH utilization management team for optimal performance management.
  • Provides counseling and corrective action when required.
  • Assists with onboarding, hiring, and training BH utilization management team members.
  • Acts as primary contact for escalated calls/issues that require research or special handling.
  • Leads and manages others in a matrixed/cross functional environment.
  • Leads and champions change within scope of responsibility.
  • Presents information and responds to questions from peers, leaders and internal/external customers.
  • Performs other duties as assigned.
  • Complies with all policies and standards.
  • Graduate of an Accredited School of Nursing or Bachelor's degree.
  • 4+ years of related experience.
  • License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required.
  • Knowledge of BH utilization management principles preferred.
  • Prior supervisory experience preferred.
  • Understanding of medical necessity criteria for a broad range of BH services preferred.
  • LCSW - License Clinical Social Worker required.
  • LMHC - Licensed Mental Health Counselor required.
  • LPC - Licensed Professional Counselor required.
  • Licensed Marital and Family Therapist (LMFT) required.
  • Licensed Mental Health Professional (LMHP) required.
  • RN - Registered Nurse - State Licensure and/or Compact State Licensure required.
  • Board Certified Behavior Analyst (BCBA) preferred.
  • 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.
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