Director, Utilization Management
Posted on: 3 Jan 2021
Raleigh, NC
Job 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.
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 states nursing license.
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.
Centene
St Louis, MO
Centene Corporation operates as a diversified and multi-national healthcare enterprise that provides programs and services to under-insured and uninsured individuals in the United States. The company’s Managed Care segment offers health plan coverage to individuals through government subsidized programs, including Medicaid, the State children’s health insurance program, long-term services and support, foster care, and medicare-medicaid plans, which covers dually eligible individuals, as well as aged, blind, or disabled programs. Its health plans include primary and specialty physician care, inpatient and outpatient hospital care, emergency and urgent care, prenatal care, laboratory and X-ray, home-based primary care, transportation assistance, vision care, dental care, telehealth, immunization, specialty pharmacy, therapy, social work, nurse advisory, and care coordination services, as well as prescriptions, limited over-the-counter drugs, medical equipment, and behavioral health and abuse services.
This segment also offers various individual, small group, and large group commercial healthcare products to employers and directly to members in the Managed Care segment.Its Specialty Services segment provides pharmacy benefits management services; health, triage, wellness, and disease management services; and vision and dental, and management services, as well as care management software that automate the clinical, administrative, and technical components of care management programs. This segment offers its services and products to state programs, correctional facilities, healthcare organizations, employer groups, and other commercial organizations. The company provides its services through primary and specialty care physicians, hospitals, and ancillary providers. Centene Corporation was founded in 1984 and is headquartered in St. Louis, Missouri.
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IndustryHealthcare
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No. of Employees47, 300
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Website
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Jobs Posted349
