Supervisor, Utilization Management

Centene Corporation•Remote-NY, NY

3d•$75,300 - $135,400•Remote

About The Position

Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team. Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards. Collaborates with utilization management team to resolve complex care member issues. Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management. Works with utilization management team and senior management to identify opportunities for process and quality improvements within 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. Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures. Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services. Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones. Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards. Assists 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

Graduation from an Accredited School of Nursing or Bachelor's degree and 4+ years of related experience.
Knowledge of utilization management principles preferred.
RN - Registered Nurse - State Licensure and/or Compact State Licensure required.
Active New York State Registered Nurse (NYS RN) licensure is required at the time of application to be considered for this role.

Nice To Haves

Knowledge of utilization management principles

Responsibilities

Supervises day-to-day activities of utilization management team.
Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards.
Collaborates with utilization management team to resolve complex care member issues.
Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management.
Works with utilization management team and senior management to identify opportunities for process and quality improvements within 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.
Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures.
Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services.
Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones.
Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards.
Assists 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.