Manager, Utilization Management

Centene Corp.; New York (NY); Remote; USD 87,000 - 161,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K

Stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements

Job summary

Centene Corporation is seeking a senior leader to manage Prior Authorization, Concurrent Review, and Appeals teams, ensuring appropriate care for members. The role requires an active RN license and a willingness to participate in weekend on-call coverage, with strong leadership, UM knowledge, and customer-service focus.

The position is remote, but candidates must reside in Oklahoma; you’ll collaborate with senior leadership, mentor staff, and drive process improvements in utilization management

Qualifications

• Requires Graduate of an Accredited School of Nursing or Bachelor's degree.
• 5+ years of related experience.
• 2+ years supervisory experience preferred.
• Knowledge of utilization management principles preferred.

Responsibilities

• Manages prior authorization, concurrent review, appeals, and retrospective reviews.
• Reviews utilization management activities and identifies improvement opportunities.
• Develops, implements, and maintains UM policies and procedures.
• Reviews UM reports to identify trends and provide recommendations to senior leadership.
• Maintains knowledge of regulations, accreditation standards, and best practices.
• Educates and provides resources for UM team and facilitates communication with members and providers.
• Collaborates with senior management to implement UM policies and guidelines.
• Provides coaching to UM team to ensure quality and performance.
• Assists leadership with onboarding, hiring, and training UM team members.
• Supports change initiatives within scope of responsibility.
• Performs other duties as assigned.

Skills

Computer literacy

Microsoft Office

Communication skills

Customer service

Time management

Education

Nursing degree

Bachelor's degree

Tools

Microsoft Office

Job description

Position Purpose:

Manages Prior Authorization, Concurrent Review, Retrospective Review Clinical Review and/or Appeals team to ensure appropriate care to members. Manages utilization management issues related to member care, provider interactions, and facilitates operations within utilization management.

Key Details:

This is a remote position, but candidates must reside in Oklahoma and hold an active RN license. The ideal candidate must be willing to participate in weekend on-call coverage and have experience in healthcare leadership, utilization management, and managed care. Candidates should be computer-savvy and proficient in Microsoft Office applications, with excellent communication and customer service skills. Strong attention to detail, organizational and management abilities, and effective time management skills are also essential for success in this role.

Responsibilities:

• Manages prior authorization, concurrent review, appeals, and/or 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:

Pay Range: $87,000.00 - $161,300.00 per year

About Centene:

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day.

You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Benefits:

• competitive pay
• health insurance
• 401K
• stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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