Senior Director, Prior Authorization Governance

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
 

Position Purpose: The Senior Director, Prior Authorization Governance is responsible for leading enterprise-wide Prior Authorization (PA) governance strategy, oversight, and optimization across all lines of business. The role partners across Clinical Operations, Medical Affairs, Compliance, Technology, Analytics, Finance, Provider Network, and Market Leadership to drive consistent enterprise decision-making and measurable business outcomes through data analytics and strategic use of AI tools. The Senior Director, PA Governance ensures PA programs are clinically appropriate, operationally efficient, compliant with regulatory requirements, and aligned with organizational objectives. Prior Authorization and Utilization Management expertise are essential to success in the role.

Responsibilities:

• Lead enterprise PA governance strategy across Medicare, Medicaid, Marketplace, Commercial, and Duals populations.

• Oversee governance structures, decision-making frameworks, and approval processes for PA requirement changes.

• Direct semi-annual and annual enterprise reviews of PA rules, code lists, and authorization requirements.

• Ensure PA criteria align with evidence-based medicine, clinical best practices, and organizational goals.

• Partner with Compliance, Legal, Medical Affairs, and Market leadership to assess regulatory impacts and mitigation strategies.

• Support Mental Health Parity and other regulatory reviews requiring PA governance oversight.

• Analyze emerging trends and identify opportunities to improve effectiveness and administrative simplification.

• Monitor impacts of PA policy changes and recommend corrective actions as needed.

• Sponsor data-driven decision making and continuous improvement initiatives.

• Lead collaboration across Clinical Operations, Behavioral Health, Medical Affairs, Technology, Compliance, Finance, Analytics, Pharmacy, Market Operations, and Provider teams.

• Develop and mentor leaders responsible for governance, optimization, and program execution activities.

• Lead enterprise PA optimization initiatives focused on reducing administrative burden and improving member and provider experience.

• Support digital utilization management strategies, automation initiatives, and AI-enabled review capabilities.

Education/Experience: Bachelor’s degree in related field or equivalent experience. 7+ years of product development/management or related experience. Experience with product planning, development, execution, and product financials. Experience across different market segments and product types.10+ years of progressive healthcare leadership experience.

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