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Director, Utilization Management

Carolina Complete Health Charlotte, North Carolina

As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.

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What does it take?

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Success Profile

  • Detail-oriented
  • Trustworthy
  • Personable
  • Quick-thinking
  • Multi-tasker
  • Good listener

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Quote

“Centene is an exciting company to work for, the pace at which we’re growing allows numerous advancement opportunities. Also, we foster an environment that supports and offers numerous leadership growth opportunities.”

- Esmeralda Baig, SVP Operations, Complex Care Products

“I assisted with one of the Provider fairs in the community. Seeing how much we care for our community and our patients was very eye opening.”

- Julie Boulch, Director, Business Implementation Health Plan Initiatives

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Responsibilities

Job ID 1144519

Category Clinical & Nursing
Schedule Full-time
Description:
Position Purpose: Oversee operations of the referral management, telephonic utilization review, prior authorization functions, and case management programs. Ensure compliance government and contractual guidelines and the mission, philosophy and objectives of Corporate and the health plan.

Oversee the operations of the referral management, telephonic utilization review, prior authorization, and case management functions.
Support and perform case management, disease management and on site concurrent review functions as necessary.
Provide support to Provider Relations issues related to Utilization issues for hospitals and physician providers.
Coordinate efforts with the Member Services and Connections Departments to address members and providers issues and concerns in compliance with medical management requirements.
Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions for the prior authorization unit.
Develop, implement and maintain policies and procedures regarding the prior authorization function.
Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes.
Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting.
Qualifications:

Education/Experience: Bachelor's degree in Nursing or equivalent experience. 5+ years of nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment. 1+ years of utilization management and/or case management experience. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.

Licenses/Certifications: Current state’s nursing license.

PA Plan Only: State license required within 90 days of hire.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
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Our Medical Roles

Clinical & Nursing Opportunities at Centene

Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.

Overall Medical Management

A member of the Centene Medical Management team, we innovate and execute strategies that redefine the industry standard for improving the lives and health of people.

Concurrent Review Nurse

To ensure our members get the best quality of care, you’ll assess acute member health conditions, treatment and intervention options, and match them with providers, community and health plan resources.

Prior Authorization Nurse

You’ll ensure our members get the best quality services, assistive devices, and equipment to promote optimal health and independence in the community and help promote health and independence.

Care Manager

Working directly with members, interdisciplinary care team, providers and data analytics, you’ll identify member health risks and conditions and intervention and service options.

LTSS Program Specialist/Program Specialist Field Based

Working directly with our most vulnerable members, you’ll identify individual member health risks and opportunities to enhance independence, quality of life and community engagement.

Referral Specialist

You’ll use our data systems to directly assist providers, requesting services and treatments for our members.

Medical Director

To help support the individual needs of members and develop programs that address issues, you’ll review population health data, help design clinical programs, and develop care delivery partnerships.

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Our Awards

Centene is consistently recognized for how well we treat our members, our people, and the communities we serve.

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“Flexibility is key. Centene is a company of change.”

Ashley Collier

Started as a Referral Specialist, now a Project Manager IV

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