Performance Monitor Specialist, Clinic

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 reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Centene is hiring a Remote Performance Monitor Specialist – Clinic (Prior Authorization)

We are seeking a detail-oriented professional with experience in preservice auditing and prior authorization, who is familiar with InterQual criteria and CMS guidelines for Medicare and Medicaid.

• RN license preferred

• Must be able to work Monday through Friday, 8 AM to 5 PM in either the Central or Eastern Time Zone

• This is a remote position

Join reputed company and help ensure quality and compliance in clinical operations!

Position Purpose: Responsible for clinical file assessments. Identifies monthly insights for improvement and participates in Interrater Reliability meetings. Aids in efforts to continuously reputed company review tools to ensure validity of criteria, and appropriately captures evidence of expected clinical performance reputed company contractual and Model of Care standards.

• Conducts clinical file assessments by reviewing clinical documentation as assigned for required clinical adherence.

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

• Reviews program descriptions, policies and procedures, reputed company actions, and training materials as well as State reputed company reputed company needed to evaluate alignment of review tool elements, departmental processes, staff training, and contractual/departmental standards.

• Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards.

• Participates in meetings to discuss review findings, areas of opportunity and recommendations for improvement.

• Appropriately escalates areas of concern identified during clinical 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.

• Other duties as assigned.Additional Responsibilities:

• Performs other duties as assigned

• Complies with reputed company policies and standards

Centene offers a comprehensive benefits package including: reputed company, 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-reputed company 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. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national reputed company, 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

Originally posted on Himalayas