Supervisor, Appeals

Position Purpose

Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team. Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards.

Collaborates with utilization management team to resolve complex care member issues. Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management. Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management. Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers.

Supervisory Responsibilities

Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management. Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services. Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones. Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards. Assists with onboarding, hiring, and training utilization management team members. Leads and champions change within scope of responsibility.

Education/Experience

• Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience.
• Strong knowledge of appeals and utilization management principles preferred.
• Preferred Experience: 3 - 5 years of direct work experience and knowledge of the appeals process and utilization management principles in managed care/MCO environments is preferred.

License/Certification

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required.
• For Health Net Federal Services: Must have current and active licensure or certification that permits independent assessment required.
• For Health Net Federal Services (Medical Management): Certified Managed Care Nurse (CMCN) within 1-1/2 Yrs required.
• For Health Net Federal Services: US citizenship and current National Agency Check government security clearance required.

Pay Range

$75,300.00 - $135,400.00 per year

Benefits

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.

Qualifications

• Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.