[Hiring] RN Supervisor @Centene Corporation

Role Description

Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team.

• Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards.
• Collaborates with utilization management team to resolve complex care member issues.
• Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management.
• Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management.
• Educates and provides resources for utilization management team on key initiatives and to facilitate ongoing communication between utilization management team, members, and providers.
• Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures.
• Works with senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services.
• Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones.
• Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards.
• Assists with onboarding, hiring, and training utilization management team members.
• Leads and champions change within scope of responsibility.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• Graduate of an Accredited School Nursing or Bachelor's degree.
• 4+ years of related experience.
• Strong knowledge of appeals and utilization management principles preferred.

Requirements

• 3 - 5 years of direct work experience and knowledge of the appeals process and utilization management principles in managed care/MCO environments is preferred.
• RN - Registered Nurse - State Licensure and/or Compact State Licensure required.
• For Health Net Federal Services: Must have current and active licensure or certification that permits independent assessment required.
• For Health Net Federal Services (Medical Management): Certified Managed Care Nurse (CMCN) within 1-1/2 Yrs required.
• For Health Net Federal Services: US citizenship and current National Agency Check government security clearance required.
• NOTE: REMOTE RN candidates may reside in any state but a current and active RN license from the state of California is strongly preferred.

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.