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.
Health Plan: Buckeye Health Plan
Line of Business: Ohio Medicaid
Team: Concurrent Review
Schedule: Monday–Friday, 8:00 a.m.–5:00 p.m.
Remote in Ohio.
Candidates must reside in Ohio and hold an active RN Ohio license.
In-person attendance is required a few times per year.
Visits may include leadership meetings, audits, and other business needs
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
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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
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