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.
Position Purpose: Provides regulatory and contractually required document management oversight the 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. Oversees the team of associates who create and maintain documentation in direct support of regulatory and accreditation requirements. Develop and oversee quality review and adherence to performance of timely documentation development, performance in internal and external audits, and support within the operational areas of PHCO. Maintain oversight monitoring of surveillance and defect reports, continual audit readiness, and drive responses to remediation plans impacting the areas supported. Provide direct support to the operational teams within PHCO for new business readiness, integrations, large scale implementations, and internal and external audits with the timely delivery of high quality documentation and supportive needs. Align and identify changes needed to strategic initiative planning alongside senior leadership to align with budgetary capabilities and supporting the needs of PHCO
- Ensures all operational processes are compliant with NCQA standards, as well as state and federal contract guidelines for documentation in policy
- Coordinates with Regulatory Affairs in each line of business to ensure that corporate policy and addendum's are compliant
- Coordinates with the Training team to ensure that training curriculum supports operational processes as defined in policies and procedures
- Coordinates schedules for review and revision of policies and procedures
- Supports the remediation and operational departmental responses to individual market EQRO/State and CMS audits
- Leads preparation of files for respective external audits
- Provides feedback to leadership team regarding audit results, opportunities for improvement, and/or required Corrective Action Plans
- 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
5+ years of regulatory, audit, oversight or healthcare delivery required
Previous lead experience including, but not limited to, responsibilities for hiring, training, assigning work and managing performance of staff required
Clinical licensure preferred and required if role charged with policy managementPay Range: $86,000.00 - $154,700.00 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
What We Do
Centene provides healthcare solutions to individuals across the United States with more than 23 million members nationwide.
