VP, PHCO Utilization Management - Medicare & Duals

Centene is transforming the health of our communities one person at a time.  As an Executive on our team, you could be the one who changes everything for our 28 million members.
 

Position Purpose: Oversee operations of the referral management, telephonic utilization review, prior authorization, and various related functions across multiple Medicare & Duals product lines at the enterprise level. Ensure compliance with contractual guidelines of the corporation and health plans impacted by numerous regulatory agencies with complex and often conflicting requirements.

• Oversee the operations of utilization management, reconciliation coordination, concurrent review (telephonic and on-site), specialty therapy programs and other related functions across multiple product lines in both centralized and multi-site regional environments
• Oversee the development and implementation of centralized and multi-site regional clinical and non-clinical training programs
• Provide strategic and tactical leadership and support to provider relations issues related to utilization issues for hospitals and physician providers
• Oversee coordination efforts with member services and the connections departments to address concerns regarding compliance with medical management requirements
• Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions, prior authorization and concurrent review units
• Collaborate with upper management to implement and maintain policies and procedures regarding the prior authorization and concurrent review functions across multiple product lines and overseen by multiple regulatory agencies
• Oversee processes used to assess quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes
• Review various reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting

Education/Experience: Bachelor's degree in Nursing, related field or equivalent experience. 10+ years of nursing, utilization management, or case management experience in an acute care setting. Experience in managed care environment. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.

License/Certification: Current state’s nursing license.

Pay Range: $182,100.00 - $345,600.00 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.

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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