RN Lead, Utilization Management & Clinical Review

Centene Corporation; Phoenix (AZ); Hybrid; USD 75,000 - 135,000; Full time

Job summary

Centene Corporation is seeking a senior supervisor for Utilization Management in the Clinical & Care Management area. The role oversees Prior Authorization, Concurrent Review, and Retrospective Review teams to ensure appropriate member care and to maintain compliance with guidelines and standards.

Requires RN licensure, a nursing degree, and 4+ years in related roles, with CMNC certification within 18 months.

Qualifications

• RN license and active state licensure required.
• Bachelor's degree in nursing or accredited nursing program and 4+ years of related experience.
• Knowledge of utilization management principles preferred.
• CMCN certification within 18 months of hire; US citizenship and security clearance required.

Responsibilities

• Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members.
• Supervises day-to-day activities of utilization management team.
• Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards.
• Collaborates with utilization management team to resolve complex care member issues.
• Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management.
• Works with utilization management team and senior management to identify opportunities for process and quality improvements within 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.
• Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures.
• Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services.
• Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones.
• Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards.
• Assists 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.

Skills

Leadership

Team supervision

Coaching

Training

Process improvement

Regulatory knowledge

Quality standards

Education

Bachelor's degree

RN license

CMCN certification

US citizenship

Security clearance

Job description

Centene Corporation is seeking a senior supervisor for Utilization Management in the Clinical & Care Management area. The role oversees Prior Authorization, Concurrent Review, and Retrospective Review teams to ensure appropriate member care and to maintain compliance with guidelines and standards.

Requires RN licensure, a nursing degree, and 4+ years in related roles, with CMNC certification within 18 months.