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