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Centene Corporation · 1 day ago

Director, Utilization Management Claims Reconsiderations

Illinois, United States

Full-time

Hybrid

Director/Executive

$134K/yr - $247K/yr

7+ years exp

Centene Corporation is a diversified national organization offering competitive benefits and a fresh perspective on workplace flexibility. The Director of Utilization Management Claims Reconsiderations will lead the utilization management team to ensure appropriate application of policies and processes, focusing on optimizing workflows and enhancing data accuracy for improved claims outcomes.

Hospital & Health Care

Responsibilities

Leads utilization management team on performance, improvement, and career growth path considerations

Leads utilization management team policies and procedures to ensure compliance with corporate, state, and National Committee for Quality Assurance (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 to senior leadership team

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

Responsible for 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

Partner closely with claims and clinical and non-clinical Utilization Management (UM) team members to align processes and improve end-to-end handling of authorization related claim issues

Direct the resolution of authorization-related denials and post claim escalations tied to authorization issues, ensuring timely and accurate outcomes

Provide strategic leadership and oversight for provider claim disputes, reconsiderations related to authorizations and/or medical necessity

Qualification

Utilization ManagementClaims ReconsiderationsManagement ExperienceIndustry Regulations KnowledgeClaims Disputes ExperienceProcess ImprovementBudget ManagementTeam Leadership