Manager, UM Operations
Fidelis Care Getzville, New York
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.
What does it take?
What are the qualities that will help you achieve success in this role at Centene?
- Good listener
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.
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.
You’ll use our data systems to directly assist providers, requesting services and treatments for our members.
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.
Category Clinical & Nursing
Position Purpose: Responsible for the management and oversight of UM operations, including the development, and implementation of process improvements, , operating policies and procedures, and reporting instruments to continuously monitor and enhance activities directly related to goals of the Utilization Management Department. Supervise and coordinate the operational activities to maximize performance and productivity in compliance with regulatory requirements. Collaboratively develop and maintain standardized data reporting instruments and related mechanisms by utilizing automated and electronic data management tools for operational monitoring and quality improvement efforts. Collect and summarize data, prepare reports, present recommendations for operational improvement within the UM department to management and implement approved process changes. Develop and implement quality improvement policies, procedures, and activities in compliance with Local, State, and Federal regulations. Ensure high quality customer service to internal and external stakeholders.
Manage supervisory level staff in the execution of Utilization Management operations to ensure regulatory compliance and corporate function; exhibit ability to communicate professionally and with cultural sensitivity.
As a member of a collaborative leadership team, oversee the ongoing operations and process improvement initiatives within the UM department, with direct oversight of Administrative Associate Supervisory teams.
Ensure appropriate tools are developed and in place to provide insight into departmental performance over time, as well as for monitoring daily operations so that adjustments can be made in real time.
Use system data to construct queries, and produce business reports: collect, analyze, and summarize data to deliver information to stakeholders, and make recommendations.
Understand regulatory requirements for all Lines of Business as well as NCQA guidelines and ensure the execution of these requirements ensuring that the organization remains consistently in compliance.
Directly lead the Administrative Associate teams and provide operational support and administrative guidance to UM Clinical teams in order to promote efficient and compliant operational performance of the Utilization Management department.
Conduct ongoing assessment of operations to ensure that needs are quickly identified so that solutions can been developed to address these needs. Make valuable process improvement recommendations to UM Director and plan for implementation. Contribute to the identification of the departmental priorities and the creation of the department roadmap.
Lead implementation of UM improvement initiatives, including providing direction on requirements and prioritization to the IT department to ensure timely execution of critical projects, both regulatory and internal
Perform validation activities related to implementation of departmental performance improvement initiatives to track efficacy and ensure results meet department expectations.
Responsible for monitoring and assessing data on inbound requests by both method (e.g., eFax, portal, phone) and type of request and evaluate for opportunities to create efficiencies. Collaborates with departmental stakeholders to prepare statistical and narrative reports on trends.
Assist in the design and improvement of auditing metrics to track performance against operating standards and regulatory performance.
Contribute to the creation and maintenance of policies and procedure/ process documentation for UM department.
Work collaboratively with UM Clinical Manager to ensure all processes are aligned and effective for both clinical and administrative teams to ensure optimal departmental performance in terms of quality, productivity, and average turnaround time.
Oversee the development of training materials and reference documents for the Associate teams to ensure appropriate orientation of new employees as well as ongoing education for existing employees.
Act as a liaison between Utilization Management and external/internal Fidelis stakeholders, participating in committees and organization-wide projects and initiatives.
Education/Experience: BA/BS - Bachelors Degree preferred; Master’s Degree Preferred. 3-6 years of related experience required; 3 years of management experience preferred. Previous experience working in a heavily regulated environment with medical, health and/or social service providers. Utilization management experience preferred. Experience monitoring compliance of departmental policies and procedures to meet organizational initiatives and regulatory requirements. Business Analysis Knowledge: Skilled to work in a fast paced environment. Must have strong analytical and problem solving skills. Customer Service: Skilled to communicate with all levels of management, internal and external customers. Effective Business Communication: Skilled in communicating with technical and business. Ability to communicate professionally and with cultural sensitivity. Ability to work well as collaborative and engage member of a team or independently.
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“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
Centene is consistently recognized for how well we treat our members, our people, and the communities we serve.Honored to be Honored
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“Flexibility is key. Centene is a company of change.”
Started as a Referral Specialist, now a Project Manager IVSee Ashley's career path
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