Centene Corporation · 13 hours ago
Supervisor, Utilization Management
United States
Full-time
Remote
Mid, Senior Level
$75K/yr - $135K/yr
4+ years expCentene Corporation is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. The Supervisor of Utilization Management is responsible for leading the clinical review team, ensuring compliance with utilization management standards, and providing guidance and support to team members in delivering appropriate care to members.
Hospital & Health Care
Responsibilities
Lead inpatient concurrent reviews for the California market and supervise the CCRN team, ensuring accurate, timely, and compliant UM decisions
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
Qualification
Required
Lead inpatient concurrent reviews for the California market and supervise the CCRN team, ensuring accurate, timely, and compliant UM decisions
RN with Utilization Management experience (health plan, managed care, or hospital UM)
Experience with appeals and retrospective reviews
Remote position -MUST LIVE IN CA
Monday–Friday
700am–500pm PST
1 month onboarding/training
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
Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience
RN - Registered Nurse - State Licensure and/or Compact State Licensure required
Preferred
Knowledge of utilization management principles preferred
Benefits
Health insurance
401K
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Flexible approach to work with remote, hybrid, field or office work schedules
Company
Centene Corporation
Centene Corporation is a leading healthcare enterprise committed to helping people live healthier lives.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Beth Johnson
President and CEO, Coordinated Care
Clyde White
President & CEO (New Hampshire Healthy Families)
Recent News
Business Journals
2024-05-06
FierceHealthcare
2024-04-28
Company data provided by crunchbase