Position Purpose: Conduct and manage the day to day operations of the referral specialist department.
Communicate with staff to facilitate daily department functions. Create a vision for the department and determine future needs.
Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease financial exposure.
Ensure that standards as defined by accrediting agencies and State contract are maintained.
Ensure compliance with federal and state regulations and contractual agreements.
Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
Facilitate on going communication between utilization management staff and contracted providers.
Education/Experience: Bachelor's degree in related field or equivalent experience. 3 years of utilization management and Medicare and/or Medicaid insurance experience. Working knowledge of Medicare and Medicaid managed care practices and policies and State Children's Health Insurance Program (SCHIP). Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
License/Certification: Certain Health Plans may require Registered Nurse with current state license.
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.