RN Performance Monitor Specialist, Clinic

🔥 18 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $56.2k - $101k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Conduct clinical file assessments by reviewing assigned clinical documentation for required clinical adherence • Participate in the development and ongoing review of clinical review tools • Review program descriptions, policies and procedures, step actions, training materials, and State Contracts as needed • Evaluate alignment of review tool elements, departmental processes, staff training, and contractual/departmental standards • Use clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs, and interventions • Participate in meetings to discuss review findings, areas of opportunity, and recommendations for improvement • Escalate areas of concern identified during clinical file reviews • Assist with preparation for State, CMS, and NCQA audits by collecting and/or reviewing relevant clinical areas • Meet established productivity and interrater reliability standards for file reviews • Follow departmental guidelines, processes, policies, and standards • Perform other duties as assigned

🎯 Requirements

• Bachelor's Degree in Nursing, Clinical Social Work/Counseling required OR Associate's degree and an RN with 3+ years of clinical experience • 3+ years of experience in a clinical environment (inpatient or outpatient) • 1+ year of experience in Managed Care (UM, BH, CM) preferred • Familiarity with Medicare and Medicaid programs preferred • A license in one of the following is required: Licensed Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), or Licensed Marital and Family Therapist (LMFT) • Certified Case Manager (CCM) preferred • RN with UM experience • Prior Authorization experience highly 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 • Additional forms of incentives may be included in total compensation • Equal opportunity employer committed to diversity

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