You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
 

Position Purpose: Analyze, develop and monitor clinical QI activities to ensure compliance with customer expectations and lead clinical quality initiatives. Review clinical information for appeals to determine medical necessity of services, prepare reviews for cases, act as the liaison for appeals and fair hearings.

• Develop and implement the quality program description, work plan goals including applicable Healthcare Effectiveness Data and Information Set (HEDIS) measures and program evaluation (trilogy documents) for behavioral health

• Lead Behavioral Health Performance Improvement Projects (PIPS)

• Review clinical information for appeals to determine medical necessity

• Prepare cases for appeals that do not meet medical necessity

• Maintain files, logs, documentation including communication in accordance with National Committee for Quality Assurance (NCQA) and State standards and regulations including timelines

• Investigate and resolve behavioral health quality of care complaints and grievances

Education/Experience: Associate’s degree in Nursing or other related field of study. 2+ years’ experience in Clinical Nursing or Behavioral Health and 1+ year of experience in Quality, Managed Care or Healthcare Administration required. Experience in Behavioral Healthcare field preferred.

For Coordinated Care - Washington only:Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Professional (LMHC), Licensed Professional Counselor (LPC), Master of Social Work (MSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (CC/LPCC), Chemical Dependency Professional (CDP).

Licenses/Certifications: Registered Nurse (RN) certification, Licensed Mental Health Professional (LMHC), or Licensed Professional Counselor (LPC) required.
 

Pay Range: $33.03 - $59.47 per hour

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.  Total compensation may also include additional forms of incentives.

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