Manager – Utilization Management
| Company | Centene |
|---|---|
| Location | Washington, USA, Oregon, USA, California, USA, Arizona, USA |
| Salary | $85300 – $158100 |
| Type | Full-Time |
| Degrees | Bachelor’s |
| Experience Level | Senior |
Requirements
- Graduate of an Accredited School of Nursing or Bachelor’s degree and 5+ years of related experience
- RN – Registered Nurse – State Licensure and/or Compact State Licensure required
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
Preferred Qualifications
- 2+ years supervisory experience preferred
- Knowledge of utilization management principles preferred
- Prior Authorization highly preferred
- Medicaid experience highly preferred