RN Supervisor, Appeals, Managed Care, UM

Centene Corporation•Remote-CA, NV

7d•$75,300 - $135,400•Remote

About The Position

Supervises the Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. This role supervises the day-to-day activities of the utilization management team, monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards. The position collaborates with the utilization management team to resolve complex care member issues, maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management, and works with the utilization management team and senior management to identify opportunities for process and quality improvements within utilization management. Additionally, the role educates and provides resources for the utilization management team on key initiatives and to facilitate on-going communication between the utilization management team, members, and providers. The supervisor monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures. They work with senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services. Performance evaluation, coaching, guidance, and assistance with onboarding, hiring, and training are also key aspects of this role. The supervisor leads and champions change within their scope of responsibility and performs other duties as assigned, while complying with all policies and standards.

Requirements

Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience.
RN - Registered Nurse - State Licensure and/or Compact State সৈন্য Licensure required.
For Health Net Federal Services: Must have current and active licensure or certification that permits independent assessment required.
For Health Net Federal Services (Medical Management): Certified Managed Care Nurse (CMCN) within 1-1/2 Yrs required.
For Health Net Federal Services: US citizenship and current National Agency Check government security clearance required.
Internal Candidates are welcome to apply if you are willing to obtain an RN license for the state of California.
The California RN license background check and RN license approval is required PRIOR to starting this role.

Nice To Haves

Strong knowledge of appeals and utilization management principles preferred.
3 - 5 years of direct work experience and knowledge of the appeals process and utilization management principles in managed care/MCO environments is preferred.
NOTE: REMOTE RN candidates may reside in any state but a current and active RN license from the state of California is strongly preferred.

Responsibilities

Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members.
Supervises day-to-day activities of utilization management team.
Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards.
Collaborates with utilization management team to resolve complex care member issues.
Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management.
Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management.
Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers.
Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures.
Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services.
Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones.
Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards.
Assists with onboarding, hiring, and training utilization management team members.
Leads and champions change within scope of responsibility.
Performs other duties as assigned.
Complies with all policies and standards.