Supervisor, Appeals

Internal Candidates are welcome to apply if you are willing to obtain an RN license for the state of California

PLEASE NOTE: The California RN license background check and RN license approval is required PRIOR to starting this role

Position Purpose: 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

Education/Experience:

Requires 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.

Preferred Experience:

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

License/Certification:

• 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

NOTE: REMOTE RN candidates may reside in any state but a current and active RN license from the state of California is strongly preferred

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

Originally posted on Himalayas