Job Information
Centene Corporation Manager, Utilization Management (Appeals) in Sacramento, California
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Candidates MUST live in the state of California
Position Purpose: Manages Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Manages utilization management issues related to member care, provider interactions, and facilitates operations within utilization management.
Manages prior authorization, concurrent review, and retrospective clinical review team and ensures compliance with applicable guidelines, policies, and procedures
Reviews and analyzes utilization management activities, operations, costs, and forecasted data to identify areas for improvement within utilization management (UM) to align to goals and objectives
Develops, implements, and maintains compliance with utilization management policies and procedures
Reviews utilization management reports to identify trends and areas of improvement and provide recommendations to senior leadership
Maintains knowledge of processes, regulations, accreditation standards, and industry best practices related to 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
Works with the senior management team to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services
Works with utilization management senior management team to provide updates and insights on team goals and objectives
Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards
Assists utilization management senior leadership 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
Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 5+ years of related experience.
2+ years supervisory experience preferred.
Knowledge of utilization management principles preferred.
License/Certification:
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required
Pay Range: $83,600.00 - $155,000.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
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.