RN Supervisor, Appeals, Managed Care, UM

🔥 0 minutes ago

🏄 California, Nebraska, +2 more states – Remote

🏄 California – Remote 🌾 Nebraska – Remote 🎸 Tennessee – Remote 🧀 Wisconsin – Remote

💵 $75.3k - $135.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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

• 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

🎯 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 • 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

🏖️ 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