Position Purpose: Responsible for clinical file assessments. Identifies monthly insights for improvement and participates in Interrater Reliability meetings. Aids 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, 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, 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