RN Performance Monitor Specialist, Clinic

Centene Corp.; Tallahassee (FL); Hybrid; USD 56,000 - 101,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K/Stock plans

Tuition reimbursement

PTO and holidays

Flexible work arrangements

Job summary

Centene Corporation in Tallahassee, Florida is seeking an RN with managed care experience to perform clinical file assessments and support evidence-based review tools. The role involves ensuring adherence to contract and Model of Care standards, while meeting productivity and IRR targets in a flexible hybrid work environment.

The ideal candidate holds a nursing degree (BSN preferred) with 3+ years in a clinical setting and knowledge of Medicare/Medicaid programs.

Qualifications

• RN with UM experience; Prior Authorization experience preferred.
• 3+ years clinical experience (inpatient or outpatient).
• Familiarity with Medicare and Medicaid programs preferred.

Responsibilities

• Conduct clinical file assessments and identify monthly insights for improvement.
• Develop and review clinical review tools to ensure adherence to standards.
• Escalate areas of concern identified during reviews and participate in audits.

Skills

RN UM experience

Prior Authorization experience

Managed Care knowledge

Education

Bachelor's Degree in Nursing

Associate degree with RN and 3+ years experience

Job description

Position Purpose:

• Responsible for clinical file assessments. Identifies monthly insights for improvement and participates in Interrater Reliability meetings. Aides in efforts to continuously develop review tools to ensure validity of criteria, and appropriately captures evidence of expected clinical performance within contractual and Model of Care standards.
• Key Details : This role is looking for RN's with UM experience; Prior Authorization experience highly preferred.
• Conducts clinical file assessments by reviewing clinical documentation as assigned for required clinical adherence.
• Participates in the development and ongoing review of clinical review tool to ensure that clinical elements accurately capture adherence with required performance standards.
• Reviews program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of review tool elements, departmental processes, staff training, and contractual/departmental standards.
• Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards.
• Participates in meetings to discuss review findings, areas of opportunity and recommendations for improvement.
• Appropriately escalates areas of concern identified during clinical file reviews.
• Participates as needed with preparation for State, CMS, and NCQA audits by collecting and /or reviewing clinical areas of relevance.
• Meets established productivity and IRR standards for file reviews.
• Follows departmental guidelines and processes.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience:

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.

Licenses and Certifications:

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.

Pay Range: $56,200.00 - $101,000.00 per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day.

You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene offers a comprehensive benefits package including:

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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