Director, Utilization Management – Authorization and Claims
Centene Corporation
full-time
Posted on:
Location Type: Remote
Location: Remote • Alabama, New Jersey, New York, Virginia • 🇺🇸 United States
Visit company websiteSalary
💰 $131,100 - $242,500 per year
Job Level
Lead
About the role
- Directs the utilization management team to ensure the appropriate application of policy procedures and processes to help support best member outcomes.
- Oversees and manages Utilization Operations specific to the daily operations of Utilization Management including timeliness, quality and performance outcomes, provider interactions and experience and associated regulatory and/or compliance measures.
- Oversees the end-to-end management of authorization reconciliation and post claim authorization functions, ensuring seamless coordination between authorization processes, claims reconciliation, and provider case resolution.
- Leads utilization management team on performance, improvement, and career growth path considerations.
- Leads utilization management team policies and procedures to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards.
- Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program.
- Leads process improvements for the utilization management team to achieve cost-effective healthcare results and presents to senior leadership team.
- Establishes policies and procedures that incorporate best practices and ensure effective utilization reviews of members.
- Develops utilization management strategies and influences decisions by providing recommendations that align to organizational objectives.
- Responsible for components of the department’s budget while collaborating inter-departmentally with senior leadership.
- Executes the overall strategy for onboarding, hiring, and training new utilization management team members to ensure adequate training and high quality-care to improve member and provider experience and ensure compliance.
- Leads and champions change within scope of responsibility.
- Partner closely with claims and clinical and non-clinical Utilization Management (UM) team members to align processes and improve end-to-end handling of authorization related claim issues.
- Direct the resolution of authorization-related denials and post claim escalations tied to authorization issues, ensuring timely and accurate outcomes.
- Provide strategic leadership and oversight for provider claim disputes, reconsiderations related to authorizations and/or medical necessity.
Requirements
- Requires a Bachelor's degree and 7+ years of related experience, including prior management experience.
- Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.
- 4+ years management experience preferred.
- Expert knowledge of industry regulations, policies, and standards preferred.
- Knowledge of claims issues related to authorizations highly preferred.
- RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred.
Benefits
- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
utilization managementauthorization reconciliationclaims reconciliationperformance improvementbudget managementstrategic leadershipprocess improvementutilization reviewdata analysishealthcare compliance
Soft skills
team leadershipcommunicationcollaborationproblem-solvingchange managementinterpersonal skillsmentoringdecision-makingorganizational skillsinfluencing
Certifications
RN - Registered NurseState LicensureCompact State Licensure