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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.

Candidate must reside in AZ. Prefer candidate to live in/around Phoenix. RN licensure and experience in clinical appeals or utilization management processes strongly preferred.

**Position Purpose:** Lead the implementation of new auditing processes and staffing oversight for audits of specific Utilization Management, Care Management Appeals activities within the organization. Provides guidance and oversight support of corrections identified by Utilization Management, Care Management, and/or Appeals leadership along with Compliance Officers regarding the requirements of accrediting and regulatory agencies, including but not limited to the Centers for Medicare and Medicaid, state Medicaid organizations, and NCQA. Leads the daily operations management of associates who monitor compliance through business monitoring audits, staff performance quality audits, surveillance and defect reports, and provides systemic report and education opportunities to executive leadership, departmental leaders and associates. Partners with senior leadership on the identification and implementation of business expansion opportunities.

+ Ensures all operational processes are compliant with NCQA standards, as well as state and federal contract guidelines

+ Coordinates monthly and quarterly audit and business monitoring results to provide systemic results and highlight opportunities for improvement

+ Ensures team is operating at high standards with minimal overturn of results based on internal standards

+ Coordinates with the Training team to ensure that training curriculum supports operational processes as defined in policies and procedures

+ Implements audit programs to ensure compliance with all operational processes

+ Collates reporting of audit results to management team and respective market leadership

+ Provides feedback to leadership team regarding audit results, opportunities for improvement, and/or required Corrective Action Plans

+ Leads Monitoring Teams responsible for research, education and conducts audits

+ Provides Compliance team performance reports to appropriate leadership representatives

+ Performs special projects as assigned

+ Performs other duties as assigned

+ Complies with all policies and standards

**Education/Experience:** Bachelor's Degree in Health Care related field, or related work experience required

4+ years of regulatory, audit, oversight or healthcare delivery required

Previous leadership, senior mentorship experience including responsibilities for hiring, training, assigning work and managing performance of staff preferred

Clinical licensure (RN) if managing team with RNs or LWCS/MSW LMHC licensure if leading team of Behavioral Health Professionals

Candidate must reside in AZ. Prefer candidate to live in/around Phoenix. RN licensure and experience in clinical appeals or utilization management processes strongly preferred.

Pay Range: $56,200.00 - $101,000.00 per year

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