Position Purpose: Plan and drive execution of Medical Management utilization programs, processes, and initiatives to ensure achievement of health benefit ratio targets, and appropriate reductions in utilization related expenses. Provide vision and strategic leadership for the development and implementation of compliant utilization management best practices across the enterprise while developing customized approaches for unique markets/product.

• Directs the collaboration within cross-functional teams to evaluate, refine, and advance the utilization management program and strategy.
• Leads data-driven decision making to advance and improve the outcomes of utilization management teams.
• Identifies and implements innovative solutions to improve the efficiency of utilization management processes across the enterprise.
• Establishes standard operating procedures to drive consistency in utilization quality and service outcomes.
• Designs data driven processes to identify areas of opportunity for improving outcomes and reducing costs.
• Leads continuous development and improvement of policies, clinical guidelines, and aligned business practices across utilization management functions.
• Innovates and implements new or revised models for UM operational functions in response to evolving trends in healthcare delivery and/or emerging models of care.
• Ensures UM processes are compliant processes and adheres to regulatory requirements.
• Defines and interprets key performance metrics to develop plans, mobilize the work force, and achieve the company’s UM goals.
• Establishes and monitors service level agreements to ensure UM programs are meeting customer (health plan, corporate partner, etc.) needs.
• Serves as a change agent, assisting others in understanding the importance, necessity, impact, and process of change through active involvement in decision making and coaching of leaders and staff.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: Bachelor's Degree in Nursing or related healthcare field or equivalent experience required.
Master's Degree in nursing or business preferred.
10+ years of experience in managed care, health plan, or provider network organizations required.
Experience with Managed Medicaid preferred.
Current nursing license required.

Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.

Pay Range: $188,900.00 - $359,800.00 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