Raleigh, North Carolina

Position Purpose:


  • Oversee operations of the referral management, telephonic utilization review, prior authorization functions, and case management programs. Ensure compliance government and contractual guidelines and the mission, philosophy and objectives of Corporate and the health plan.
  • Oversee the operations of the referral management, telephonic utilization review, prior authorization, and case management functions.
  • Support and perform case management, disease management and on site concurrent review functions as necessary.
  • Provide support to Provider Relations issues related to Utilization issues for hospitals and physician providers.
  • Coordinate efforts with the Member Services and Connections Departments to address members and providers issues and concerns in compliance with medical management requirements.
  • Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions for the prior authorization unit.
  • Develop, implement and maintain policies and procedures regarding the prior authorization function.
  • Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes.
  • Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting.


Education/Experience: Bachelor's degree in Nursing or equivalent experience. 5+ years of nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment. 1+ years of utilization management and/or case management experience. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.

Licenses/Certifications: Current state’s nursing 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.

Raleigh, North Carolina

Centene Corporation, a Fortune 500 company, is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government sponsored healthcare programs, focusing on under-insured and uninsured individuals. Many receive benefits provided under Medicaid, including the State Children's Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long Term Care (LTC), in addition to other state-sponsored/hybrid programs, and Medicare (Special Needs Plans). The Company operates local health plans and offers a range of health insurance solutions. It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, correctional healthcare services, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and telehealth services.

Similar jobs