Clinical Manager, Appeals and Grievances
Company: Centene
Location: Shawnee
Posted on: November 18, 2023
|
|
Job Description:
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.
Must live in Oklahoma
Oklahoma Complete Health, a Centene company, is committed to
providing quality healthcare solutions to transform the health of
Oklahomans.
At Oklahoma Complete Health, we are community advocates and
change-makers in search of an inclusive culture grounded by our
commitment to work-life balance, competitive compensation, and
continuous career development. Join us and be a part of a
collaborative, growing network of innovative thinkers delivering
solutions at the local level.
Position Purpose: Supervise nurses in a highly regulated department
responsible for performing medical necessity case reviews for
appropriateness of medical care and service. Supervise the day to
day clinical operations and functions within the department,
ensuring productivity and quality metrics are met.
Ensure that the Clinical Appeals and Grievances unit processes all
appeals in accordance with referred time frames and other
contractual legal requirements. Ensure that clinical team is
reviewing the appeals in accordance with clinical policies and
using appropriate NDL and LDL to make appropriate decisions
Monitor appeals and provide senior management with monthly
reporting on trends
Confer with staff to review new projects, status of work in
progress, problems encountered, and ensure compliance with
departmental policies and procedures.
Work with various external constituencies, i.e., state, local and
federal governments, local community and the public related to
grievance and appeals
Integrate federal and state law changes into company's regulatory
system related to grievance and appeals
Recommend solutions and works with department and company staff to
ensure problems are corrected and departments are advised of
corrective measures to prevent recurrences
Provide coverage for internal and external program audits.
Travel to other states 10% of the time.
Education/Experience: Bachelor's degree in related field or
equivalent experience. Clinical, quality management or healthcare
related experience and recent supervisory experience in a
healthcare environment, preferably managed care. Three years of
experience required. 3+ years of supervisory/management
experience
License/Certification: Current state RN license required. Certified
Professional in Healthcare or other licensed clinical experience
preferred.
Our Comprehensive Benefits Package: Flexible work solutions
including remote options, hybrid work schedules and dress
flexibility, Competitive pay, Paid time off including holidays,
Health insurance coverage for you and your dependents, 401(k) and
stock purchase plans, Tuition reimbursement and best-in-class
training and development.
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.
Keywords: Centene, Midwest City , Clinical Manager, Appeals and Grievances, Executive , Shawnee, Oklahoma
Click
here to apply!
|