Position Purpose: Oversees the care plans / service plans and care management activities of member needs to provide quality, cost-effective healthcare outcomes. Reviews and provides expert knowledge to inform personalized care plans / service plans for complex care members and provides guidance and/or support to the care management team.

Key Details: Seeking remote RN (speciality pharmacy experience a plus) to work in an Inbound/Outbound Call Center Environment.

• Oversees and reviews ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources needed to address member's unmet needs
• Provides insight and guidance on developing care plans / service plans and triaging issues to appropriate healthcare providers for care plans / service plans
• Provides guidance and expert knowledge as appropriate to care management team members to ensure quality control over work, members are receiving needed care or services, and adherence to contract policies and procedures
• Monitors the care plans / service plans and/or member status and outcomes or changes in condition, and revises care plan based on member needs and issues identified
• Provides subject matter expertise insights for care plans / service plans based on prior experience to recommend enhanced member care within the care management plan
• Works with senior management on escalated and complex care cases, and provides guidance to junior team members to address member concerns
• May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
• Reviews member data to identify health risks and or care gaps, collaborate with providers / specialists as appropriate to address member’s needs / issues
• Monitors management policies and procedures within the care management team to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards
• Partners and collaborates with healthcare providers as appropriate to facilitate member’s treatments to ensure member service / care needs are met and determine a revised care plan / service plan for member if needed
• Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators
• Works as a subject matter expert (SME) and provides training and education to care management team and providers to ensure members are receiving high quality care and information regarding care plan / service plan options, procedures, referrals, and healthcare benefits
• Partners with leadership team to improve and enhance care and quality delivery for members in a cost-effective manner
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 5 – 7 years of related experience.

License/Certification:

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required

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