Supervisor, Clinical Grievance and Appeals

Centene; United States; Remote; USD 68,000 - 124,000; Full time

Job summary

A leading company is seeking a clinical professional to supervise a team of nurses in their Medical Management department. This role involves overseeing medical necessity reviews and ensuring compliance with regulations. Ideal candidates will have a Bachelor's degree in Nursing and significant nursing experience.

Benefits

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Qualifications

• 3+ years of combined nursing and appeal experience required.
• Previous supervisory experience strongly preferred.
• Knowledge of coding and DHCS/DMHC regulations preferred.

Responsibilities

• Supervise nurses and oversee clinical operations.
• Ensure compliance with state/federal regulations and NCQA standards.
• Train and onboard new team members.

Skills

Clinical expertise

Problem solving

Process improvement

Education

Bachelor's degree in Nursing

Tools

Microsoft Office

Job description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Candidates MUST reside in North Carolina.

Position Purpose: Supervise nurses in a highly regulated department responsible for performing medical necessity case reviews for appropriateness of medical care and service. Supervise the day to day clinical operations and functions within the department, ensuring productivity and quality metrics are met.

• Provide oversight and interpretation of state/federal regulations and NCQA standards impacting member appeals and grievances from a clinical perspective. Ensure that the clinical Appeals and Grievance department processes all cases in accordance with policies and procedures
• Utilize clinical expertise to serve as a resource to the team regarding escalated or complex clinical issues
• Monitor and distribute team’s caseload and ensure adequate coverage
• Monitor and evaluate performance standards and provide feedback and guidance or problem resolution.
• Identify and develop opportunities for process improvement and work with various leaders to ensure problems are corrected
• Train and onboard new team members
• Audit staff to standards and provide continuous feedback
• Assist management in committee work, regulatory audits and regulatory reporting.
• Analyze and interpret state and federal regulatory requirements and NCQA standards and provide guidance to team to ensure adherence

Education / Experience: Bachelor's degree in Nursing preferred. 3+ years of combined nursing and appeal and grievance, or utilization management or case management experience. Previous supervisory experience strongly preferred. Proficient with Microsoft Office applications. Knowledge of coding preferred. Previous Quality Improvement experience preferred. Knowledge of DHCS/DMHC regulations preferred.

Licenses, Certifications: LPN Required (RN preferred) Pay Range: $68,700.00 - $123,700.00 per year

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and 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. Total compensation may also include additional forms of incentives.

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