Centene Corporation
Director, Utilization Management Authorization and Claims
Centene Corporation, Louisiana, Missouri, United States, 63353
Director, Utilization Management Authorization and Claims
Centene Corporation is looking for a Director, Utilization Management Authorization and Claims to manage the utilization management team overseeing authorization reconciliation, claims reconciliation, provider interactions and compliance.
Position Purpose Directs the utilization management team to ensure the appropriate application of policy procedures and processes to support best member outcomes. Oversees daily operations of utilization management including timeliness, quality and performance outcomes, provider experience and compliance. Manages end-to-end authorization reconciliation and post‑claim functions, optimizing workflows, enhancing data accuracy and driving efficiency.
Key Responsibilities
Lead the utilization management team on performance, improvement and career growth.
Develop and enforce policies and procedures that meet corporate, state and NCQA standards.
Analyze and report utilization trends and impacts to deliver an effective utilization program.
Drive process improvements for cost‑effective healthcare results and present findings to senior leadership.
Establish best‑practice policies for member utilization reviews.
Develop utilization strategies and provide recommendations aligned to organizational objectives.
Manage departmental budget components and collaborate with senior leadership.
Oversee onboarding, hiring and training of new team members to ensure high quality care and compliance.
Champion change within scope of responsibility.
Partner with claims and clinical/non‑clinical UM teams to align processes and improve end‑to‑end handling of authorization related claim issues.
Direct timely resolution of authorization‑related denials and post‑claim escalations.
Provide strategic leadership over provider claim disputes and reconsiderations related to authorizations or medical necessity.
Education and Experience
Bachelor’s degree and 7+ years of related experience, including prior management experience.
4+ years of management experience preferred.
Expert knowledge of industry regulations, policies and standards preferred.
Knowledge of claim issues related to authorizations highly preferred.
Experience with claims disputes and reconsiderations highly preferred.
Compensation Pay Range: $131,100.00 – $242,500.00 per year. Compensation may include additional incentives. Benefits include health insurance, 401(k), stock purchase plans, tuition reimbursement, paid time off and holidays with flexible work arrangements.
EEO Statement Centene is an equal opportunity employer that is committed to diversity. 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 protected characteristics. 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 daily operations of utilization management including timeliness, quality and performance outcomes, provider experience and compliance. Manages end-to-end authorization reconciliation and post‑claim functions, optimizing workflows, enhancing data accuracy and driving efficiency.
Key Responsibilities
Lead the utilization management team on performance, improvement and career growth.
Develop and enforce policies and procedures that meet corporate, state and NCQA standards.
Analyze and report utilization trends and impacts to deliver an effective utilization program.
Drive process improvements for cost‑effective healthcare results and present findings to senior leadership.
Establish best‑practice policies for member utilization reviews.
Develop utilization strategies and provide recommendations aligned to organizational objectives.
Manage departmental budget components and collaborate with senior leadership.
Oversee onboarding, hiring and training of new team members to ensure high quality care and compliance.
Champion change within scope of responsibility.
Partner with claims and clinical/non‑clinical UM teams to align processes and improve end‑to‑end handling of authorization related claim issues.
Direct timely resolution of authorization‑related denials and post‑claim escalations.
Provide strategic leadership over provider claim disputes and reconsiderations related to authorizations or medical necessity.
Education and Experience
Bachelor’s degree and 7+ years of related experience, including prior management experience.
4+ years of management experience preferred.
Expert knowledge of industry regulations, policies and standards preferred.
Knowledge of claim issues related to authorizations highly preferred.
Experience with claims disputes and reconsiderations highly preferred.
Compensation Pay Range: $131,100.00 – $242,500.00 per year. Compensation may include additional incentives. Benefits include health insurance, 401(k), stock purchase plans, tuition reimbursement, paid time off and holidays with flexible work arrangements.
EEO Statement Centene is an equal opportunity employer that is committed to diversity. 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 protected characteristics. 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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