Vice President, Utilization Management
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Job Description
Vice President leading Centene’s utilization management strategy and healthcare cost optimization. Driving compliant programs, clinical guidelines, metrics, and cross-functional execution.
Responsibilities:
- Plan and drive execution of Medical Management utilization programs, processes, and initiatives
- Ensure achievement of health benefit ratio targets and appropriate reductions in utilization-related expenses
- Provide vision and strategic leadership for compliant utilization management best practices across the enterprise
- Develop customized approaches for unique markets/products
- Direct collaboration within cross-functional teams to evaluate, refine, and advance utilization management programs and strategy
- Lead data-driven decision-making to improve utilization management team outcomes
- Identify and implement innovative solutions to improve utilization management process efficiency
- Establish standard operating procedures for consistency in utilization quality and service outcomes
- Design data-driven processes to identify opportunities to improve outcomes and reduce costs
- Lead continuous development and improvement of policies, clinical guidelines, and aligned business practices
- Innovate and implement models for utilization management operational functions in response to healthcare delivery trends and emerging care models
- Ensure utilization management processes comply with regulatory requirements
- Define and interpret key performance metrics, develop plans, mobilize the workforce, and achieve company utilization management goals
- Establish and monitor service level agreements to meet customer needs
- Serve as a change agent through decision-making and coaching of leaders and staff
- Perform other duties as assigned
- Comply with all policies and standards
Requirements:
- Bachelor's Degree in Nursing or related healthcare field or equivalent experience required
- 10+ years of experience in managed care, health plan, or provider network organizations required
- Current nursing license required
- Experience with Managed Medicaid preferred
- Master's Degree in nursing or business preferred
- Equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position
Benefits:
- Competitive pay
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation, subject to program eligibility
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