Centene Corporation
Director, Utilization Management Authorization and Claims
Centene Corporation, New York, New York, United States
Director, Utilization Management Authorization and Claims
Located in Georgia, United States.
Position Purpose Directs the utilization management team to ensure the appropriate application of policy procedures and processes to support best member outcomes. Oversees Utilization Operations including timeliness, quality, performance outcomes, provider interactions, and compliance measures. Manages authorization reconciliation and post‑claim authorization functions, coordinating processes, claims reconciliation, and provider case resolution to drive efficiency and compliance.
Responsibilities
Leads the utilization management team on performance, improvement, and career growth path considerations.
Guides utilization management team policies and procedures to ensure compliance with corporate, state, and NCQA standards.
Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program.
Leads process improvements for the utilization management team to achieve cost‑effective healthcare results and presents findings to senior leadership.
Establishes policies and procedures that incorporate best practices and ensure effective utilization reviews of members.
Develops utilization management strategies and influences decisions by providing recommendations that align to organizational objectives.
Manages components of the department’s budget while collaborating inter‑departmentally with senior leadership.
Executes the overall strategy for onboarding, hiring, and training new utilization management team members to ensure adequate training and high‑quality care to improve member and provider experience and ensure compliance.
Leads and champions change within scope of responsibility.
Partners closely with claims and clinical and non‑clinical UM team members to align processes and improve end‑to‑end handling of authorization‑related claim issues.
Directs the resolution of authorization‑related denials and post‑claim escalations tied to authorization issues, ensuring timely and accurate outcomes.
Provides strategic leadership and oversight for provider claim disputes, reconsiderations related to authorizations and/or medical necessity.
Education & Experience Requires a Bachelor’s degree and 7+ years of related experience, including prior management experience, or equivalent experience achieved through accomplishments reflecting the level of this position. At least 4 years of management experience is preferred. Expert knowledge of industry regulations, policies, and standards is preferred. Knowledge of claims issues related to authorizations and experience with claims disputes and reconsiderations is highly preferred.
Compensation Pay Range: $131,100.00 – $242,500.00 per year.
Benefits Comprehensive benefits package including competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office schedules.
Equal Opportunity Employer 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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Position Purpose Directs the utilization management team to ensure the appropriate application of policy procedures and processes to support best member outcomes. Oversees Utilization Operations including timeliness, quality, performance outcomes, provider interactions, and compliance measures. Manages authorization reconciliation and post‑claim authorization functions, coordinating processes, claims reconciliation, and provider case resolution to drive efficiency and compliance.
Responsibilities
Leads the utilization management team on performance, improvement, and career growth path considerations.
Guides utilization management team policies and procedures to ensure compliance with corporate, state, and NCQA standards.
Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program.
Leads process improvements for the utilization management team to achieve cost‑effective healthcare results and presents findings to senior leadership.
Establishes policies and procedures that incorporate best practices and ensure effective utilization reviews of members.
Develops utilization management strategies and influences decisions by providing recommendations that align to organizational objectives.
Manages components of the department’s budget while collaborating inter‑departmentally with senior leadership.
Executes the overall strategy for onboarding, hiring, and training new utilization management team members to ensure adequate training and high‑quality care to improve member and provider experience and ensure compliance.
Leads and champions change within scope of responsibility.
Partners closely with claims and clinical and non‑clinical UM team members to align processes and improve end‑to‑end handling of authorization‑related claim issues.
Directs the resolution of authorization‑related denials and post‑claim escalations tied to authorization issues, ensuring timely and accurate outcomes.
Provides strategic leadership and oversight for provider claim disputes, reconsiderations related to authorizations and/or medical necessity.
Education & Experience Requires a Bachelor’s degree and 7+ years of related experience, including prior management experience, or equivalent experience achieved through accomplishments reflecting the level of this position. At least 4 years of management experience is preferred. Expert knowledge of industry regulations, policies, and standards is preferred. Knowledge of claims issues related to authorizations and experience with claims disputes and reconsiderations is highly preferred.
Compensation Pay Range: $131,100.00 – $242,500.00 per year.
Benefits Comprehensive benefits package including competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office schedules.
Equal Opportunity Employer 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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