Job description

You could be the one who changes everything for our 26 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.

Position Purpose: Oversee the day-to-day quality review function, ensuring accurate and timely review of department processes to ensure compliance with applicable state, federal and accrediting body requirements.

Provide supervision for appeals and grievance, quality of care/service; provider redeterminations and other applicable department activities including policies, procedures, workflows, letters, and reports.

Communicate and reinforce standards for the quality team

Prepare any applicable department state, federal, or accrediting body reports and submit timely.

Prepare other quality review reports on departmental findings, identifying individual and organizational trends

Identify and analyze team performance trends, address barriers, and recommend process improvements.

Ensure non-clinical and clinical audits are conducted according to established tools and standards

Provide recommendations for development, or revision of policies, procedures, work flows, documents or other documents to be used for training content or skill acquisition

Research and respond to complex quality of care or quality of service, appeal and grievance or provider redetermination inquiries.

Coordinate with management to ensure the department output is meeting goals, expectations and requirements in alignment with the quality improvement department and program description and work plans.

Education/Experience: LPN/LVN or graduate from an Accredited School of Nursing and RN License. Bachelor’s degree in related field preferred.5+ years of clinical experience in health care. Managed care experience preferred. Previous experience in supervisory role, quality assurance preferred. Strong computer skills, including experience with Microsoft office and/or quality monitoring systems

License/Certificates: LPN/LVN or RN license without restriction in the state of residence.

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

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.

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