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.
RN license for state of California required.
Position Purpose: Manages the care management team and the care management of members to develop and assess high quality, cost-effective healthcare outcomes. Manages escalations and care management issues related to members or providers.
Oversees and reviews care management required documentation to maintain compliance with federal and state regulations and contractual agreements
Contributes to the development and implementation of policies and procedures within the care management team based on regulatory requirements and industry standards
May direct the daily activities of care management staff including reviewing and approving the caseloads based on state requirements, care management staff experience, and member needs
Manages processes for escalation and/or complex cases, and provides guidance to team members to address member needs
May manage or coordinate resolutions of member escalations and/or complaints and assists in audits and evaluations related to care programs and member concerns
Contributes to the development, implementation, and oversight of care management programs to facilitate the use of appropriate services and resources
May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
Sets goals and objectives for care management team and oversees care management data and reporting metrics to achieve quality and cost-effective healthcare results and works with senior leadership, as required
Monitors audits within care management to ensure compliance with regulatory requirements for federal, state, and National Committee for Quality Assurance (NCQA) standards, as required
Provides feedback to care management team to improve member and provider experience and high-quality care
Educates and provides resources for care management team on key initiatives and member outreach to facilitate on-going communication between care management team, members, and providers
Assists care management senior leadership with onboarding, hiring, and training care management team members
Leads and champions change within scope of responsibility
Performs other duties as assigned
Complies with all policies and standards
Education/Experience: Requires Graduate from an Accredited School or Nursing or a Bachelor's degree and 5+ years of related experience.
*Prefer UM and CM experience.
License/Certification:
Location: Position is remote. Will work PST hours.
Pay Range: $102,900.00 - $190,500.00 per yearCentene 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
Centene Corporation is a diversified, national healthcare organization serving 28 million members across the United States. The company operates multiple state health plans, including Fidelis, and focuses on transforming community health through managed care services. Centene provides comprehensive healthcare management services including medical necessity reviews, prior authorization processes, cost containment initiatives, and fraud, waste, and abuse prevention programs. The organization emphasizes quality care delivery and cost-effectiveness while maintaining regulatory compliance with Medicare, Medicaid, and state-specific healthcare requirements.
