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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.

Experience in Heath Insurance and UM highly preferred

Position Purpose:

Responsible for nonclinical (CMC, PSO, UM, DME) file audits. Identifies monthly insights for improvement and participates in Interrater Reliability meetings. Aids in efforts to continuously develop review tools to ensure validity of criteria, and appropriately captures evidence of expected clinical performance within contractual and Model of Care standards.

+ Conducts nonclinical (CMC, PSO, UM, DME) file assessments by reviewing nonclinical documentation as assigned for required adherence.

+ Participates in the development and ongoing review of nonclinical review tool to ensure that nonclinical elements accurately capture adherence with required performance standards.

+ Reviews nonclinical program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of review tool elements, departmental processes, staff training, and contractual/departmental standards.

+ Utilizes knowledge and experience to evaluate nonclinical team documentation.

+ Participates in meetings with coordination teams and others to discuss review findings, areas of opportunity and recommendations for improvement.

+ Appropriately escalates areas of concern identified during nonclinical file reviews.

+ Participates as needed with preparation for State, CMS, and NCQA audits by collecting and /or reviewing clinical areas of relevance.

+ Meets established productivity and IRR standards for file reviews.

+ Follows departmental guidelines and processes.

+ Assist with special projects and other duties as assigned.

+ Performs other duties as assigned

+ Complies with all policies and standards

Education/Experience:

High School Diploma or equivalent required. Bachelors degree in a related field preferred. 3+ years of experience in a managed care setting, medical office, or facility setting with a demonstration of medical administration duties required. Familiarity with Medicare and Medicaid programs preferred.

Pay Range: $19.04 - $32.35 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, 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