Centene Corporation logo
Centene Corporation

Transforming the health of the communities we serve, one person at a time.

Supervisor, Appeals

SupervisorGeneralFull TimeRemoteSeniorTeam 10,001+Since 1984H1B No SponsorCompany SiteLinkedIn

Location

California + 3 moreAll locations: California | Nebraska | Tennessee | Wisconsin

Posted

2 days ago

Salary

$75.3K - $135.4K / year

Seniority

Senior

Bachelor Degree4 yrs expEnglish

Job Description

Supervisor, Appeals

Centene Corporation

• 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 on-going 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 the 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

Job Requirements

  • Graduate of an Accredited School Nursing or Bachelor's degree
  • 4+ years of related experience
  • Strong knowledge of appeals and utilization management principles preferred
  • 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
  • Must have current and active licensure or certification that permits independent assessment required
  • 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 for Health Net Federal Services

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

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