Supervisor, Appeals

Centene Corporation•Remote-CA, NE

3d•$75,300 - $135,400•Remote

About The Position

Centene is seeking a Supervisor, Appeals to join their Medical Management/Health Services team. This role will supervise a clinical review team responsible for Prior Authorization, Concurrent Review, and/or Retrospective Review to ensure appropriate care for members. The position involves managing day-to-day activities, monitoring UM resources for performance and compliance, and collaborating to resolve complex member issues. The supervisor will stay updated on regulations and industry best practices, identify process improvements, and educate the team on key initiatives. They will also monitor team performance, provide feedback, coaching, and guidance, and assist with hiring and training. This role is crucial in developing and implementing UM policies and procedures to ensure effective utilization of healthcare services.

Requirements

Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience.
Strong knowledge of appeals and utilization management principles preferred.
RN - Registered Nurse - State Licensure and/or Compact State 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.

Nice To Haves

3 - 5 years of direct work experience and knowledge of the appeals process and utilization management principles in managed care/MCO environments is preferred.
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 the 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.