Position Purpose: Manages the behavioral health (BH) utilization review clinicians to ensure appropriate care to members. Oversees and works with senior leadership on utilization management issues related to member care, provider interactions, and facilitates operations within utilization management.
This is a remote opportunity supporting BH UM. Applicants must one of the following active clinical licenses: LCSW, LMHC, LPC, LMFT, LMHP, or RN.
Oversees the behavioral health (BH) utilization review clinicians and ensures compliance with applicable guidelines
Reviews and analyzes BH utilization management (UM) activities, over/under utilization, operations, costs, and forecasted data to identify areas for improvement within UM to align to goals and objectives
Manages and tracks achievement against goals and objectives and HBR performance for BH utilization management team to achieve cost-effective healthcare results and to ensure appropriate care to members
Manages and reviews BH utilization management and financial reports to identify trends and areas of improvement and provide recommendations to BH senior leadership
Oversees processes, regulations, contractual and accreditation standards, and industry best practices related to BH utilization management to ensure compliance with BH utilization management policies and procedures
Identifies process improvements for the BH utilization management team to achieve cost- effective healthcare results and presents to BH senior leadership team
Works with the BH senior leadership team to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services
Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers
Oversees the People Leader in the training of BH utilization management team members to ensure adequate training and high-quality care to BH members
Supports in developing the overall strategy for onboarding, hiring, and training new BH utilization management team members
Provides support and career development feedback to Supervisors
Leads talent management activities to develop and cultivate future leaders.
Attends company meetings in absence of people leader
Effectively manages escalated calls/issues that require additional research or special handling
Leads and manage others in a matrixed/cross functional environment with tight timeframes and strict deadlines
Leads and champions change within scope of responsibility
Effectively presents information and responds to questions from peers, leaders and internal/external customers
Performs other duties as assigned
Complies with all policies and standards
Education/Experience:
Requires Graduateof an Accredited School of Nursing or Bachelor's degree and 6+ years of related experience, including prior management experience.
3+ years management experience preferred.
License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required.
Strong knowledge of utilization management principles preferred.
Advanced understanding of medical necessity criteria for a broad range of BH services preferred.
License/Certification:
LCSW- License Clinical Social Workerrequired or
LMHC-Licensed Mental Health Counselor required or
LPC-Licensed Professional Counselor required or
Licensed Maritaland Family Therapist (LMFT) required or
Licensed Mental Health Professional(LMHP) required or
RN - Registered Nurse - State Licensure and/or Compact State Licensure required
Pay Range: $102,900.00 - $190,500.00 per year
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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
Originally posted on Himalayas