You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: Oversees correspondence letters based and supports overall team needs. Reviews outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.
- Oversees the clinical review of outcomes including creating and editing correspondence letters with the correspondence team based on determinations in accordance with National Committee for Quality Assurance (NCQA) standards
- Manages the audits of correspondence to ensure they are processed in accordance with Federal, State, and NCQA standards
- Provides expert insight and guidance on the clinical review process of correspondence to ensure compliance with all applicable State and Federal regulations
- Provides subject matter expertise insights to investigate and resolve issues including comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and escalates as appropriate to resolve issues in a timely manner
- Acts as a point of contact for escalated, advanced issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer and providers to ensure issues are resolved in a timely manner
- Oversees clinical quality and process improvement initiatives related to clinical quality indicators and financial metrics
- Manages data needed to identify trends and provide recommendations to senior management of process improvements within utilization management
- Manages and oversees cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
- Provides training and education to the interdepartmental teams on training needed within the utilization management team based on trends
- Partners with leadership to improve processes and procedures to prevent recurrences based on industry best practices
- Provides guidance, subject matter expertise and training as needed
- Performs other duties as assigned
- Complies with all policies and standards
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 5 – 7 years of related experience.
Expert knowledge of Medicare and Medicaid regulations preferred.
Expert knowledge of utilization management processes preferred.
License/Certification:- LPN - Licensed Practical Nurse - State Licensure required
- For Health Net of California: RN license required
Pay Range: $35.49 - $63.79 per hour
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