You could be the one who changes everything for our 28 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.

A related New York certification or licensure is required for this roleThis is a Monday

• Friday 8:30 - 5:00 pm EST salaried role.

Position Purpose: Incumbent is responsible for the design, development and operational leadership of the Clinical Business Monitoring Team. Partner with Clinical Leadership to enhance and implement use of monitoring tools, specific defect and exception reports, implement process improvements, and develop training plans for clinical and non-clinical staff aimed at improving operational execution and compliance to state, federal and accrediting regulations and requirements. Develops and employs process monitoring tools to identify root cause of potential process deficiencies, and provides timely reporting on productivity, audit results and process improvement opportunities. Responsible for operational knowledge and subject matter expert for regulatory specifications for the business – Medicare and/or Medicaid – that govern both Utilization Management and Case Management functions as it relates to those regulations. Lead the business/operational translation specifications to the IT team for universe creation. Participate in Universe governance that would impact changes to the specification and ultimately impact compliance.

• Manages and develops direct reports who include supervisory and/or exempt professional personnel including but not limited to hiring, mid-year and annual reviews, Performance Improvement Plans (PIP), terminations, etc.

• Ensures department activities are compliant with the regulations and standards that govern the industry.

• Coordinates with Regulatory Affairs in each line of business to ensure that corporate policy and addendums are compliant.

• Develops and implements departmental workflows and policies & procedures.

• Collaborates with other departments cross functionally regarding case management and/or Clinical Services initiatives.

• Partners with Management team to develop audit plans that identifies and prioritizes areas of significant risk.

• Reviews and audits the effectiveness of corrective action plans that address report findings and provides comprehensive follow-up to senior management at least monthly.

• Develops, implements and manages process improvement initiatives.

• Manages audit planning, including review of audit programs for multiple performance reviews specific to role or department.

• Applies a comprehensive knowledge of Care Model for telephonic and field care management programs.

• Proactively monitors appropriate metrics to improve both quality and drive efficiency.

• Partners with key stakeholders across clinical and non-clinical departments during external and internal audits in order to provide appropriate documentation and communication to ensure the audits are conducted in accordance with audit methodology, professional standards, NCQA, CMS, and state Medicaid requirements.

• Develops QA standards to monitor and improve adherence to department standards, policies and procedures, templates, formats and guidelines.

• Develops and implements studies of business function systems to include performance audit scores, action plans, and analysis.

• Prepares narratives and graphic display of the findings.

• Direct involvement in building collaborative relationships with other departments to resolve quality issues and barriers, i.e Provider Network, Quality, Advocacy, Utilization Management, etc.

• Performs special projects as needed.

• Performs other duties as assigned

• Complies with all policies and standards

Education/Experience:A related New York certification or licensure is required for this roleRequired A Bachelor's Degree in Public Health, Nursing, Healthcare Administration, Business Management or related field: Required or equivalent work experience 5+ years in nursing, a clinical setting, managed care, or business reporting/analytics

Candidate Experience:

Required 5+ years of experience in practical work in a business environment with data collection, creation and analytics
Required 2+ years experience in leading/supervising others
Preferred 2+ years of experience in An acute clinical care setting and/or managed care related experience
Preferred 2+ years of experience in Case management
Preferred 2+ years of experience in reading, analyzing, interpreting and/or applying State and Federal laws, rules and regulations

Licenses and Certifications:

A license in one of the following is required: Preferred Other One or more of the below

Preferred Project Management Professional (PMP): Preferred Certified Business Analysis Professional (CBAP):

Preferred Licensed Registered Nurse (RN)
Preferred Licensed Certified Social Worker (LCSW)
Preferred Licensed Marital and Family Therapist (LMFT)
Preferred Licensed Mental Health Counselor (LMHC)

Preferred Certified Case Manager (CCM):

Pay Range: $87,700.00 - $157,800.00 per year

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