RN Utilization Management Lead (Remote/Hybrid)

Centene Corporation; California (MO); Hybrid; USD 75,000 - 135,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Job summary

Centene Corporation seeks a Nursing leader in Utilization Management to monitor UM resources, collaborate with the UM team on care member issues, and ensure adherence to regulations and standards. This role drives process improvements and mentors staff while advancing quality initiatives across programs.

The position requires an RN license (CA) and a Bachelor's degree in Nursing, with 4+ years of related experience.

Qualifications

• Requires nursing degree and 4+ years of related experience.
• Knowledge of utilization management principles preferred.

Responsibilities

• 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.
• Work with UM team and senior management to identify opportunities for process and quality improvements within UM.
• Educates and provides resources for UM team on key initiatives and to facilitate communication between UM team, members, and providers.
• Monitors prior authorization, concurrent review, and retrospective clinical review nurses and ensures compliance with guidelines, policies, and procedures.
• Develops and implements UM policies, procedures, and guidelines to ensure appropriate utilization of healthcare services.
• Evaluates UM team performance and provides feedback on performance, goals, and career milestones.
• Provides coaching and guidance to UM team to ensure adherence to quality and performance standards.
• Assists with onboarding, hiring, and training UM team members.
• Leads and champions change within scope of responsibility.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education

Bachelor's degree in Nursing

Job description

Centene Corporation seeks a Nursing leader in Utilization Management to monitor UM resources, collaborate with the UM team on care member issues, and ensure adherence to regulations and standards. This role drives process improvements and mentors staff while advancing quality initiatives across programs.

The position requires an RN license (CA) and a Bachelor's degree in Nursing, with 4+ years of related experience.