Position Purpose: Supervise the day to day operations of the case management function. Communicate with departmental and plan administrative staff to facilitate daily department functions.
Assure compliance with established referral, pre-certification and authorization policies, procedures and processes by related Medical Services staff.
Assure compliance with established onsite and concurrent review, case management, referral, pre-certification and authorization policies, procedures and processes.
Assure compliance with emergency management policies, procedures and processes.
Facilitate on-going communication between case management staff, utilization management staff and contracted providers.
Assist with the implementation of policies and procedures regarding medical case management.
Maintain compliance with federal and state regulations and contractual agreements.
Coordinate and communicate medical service functions with other departmental functions.
Act as medical resource for appeals function.
Assist Medical Services staff with computer systems issues related to case management.
Conduct telephonic review of cases with doctors, hospitals, and other providers.
Compile and review multiple reports for statistical and financial tracking purposes to identify case management trends and assist in financial forecasting.
Education/Experience: 3+ years of nursing experience in an acute care setting particularly in a medical/surgical, pediatrics, or obstetrics environment. 1+ year of case and/or utilization management experience. Working knowledge of a specialized or technical field such as clinical nursing, case and/or utilization management. Previous experience as a lead in a functional area or managing cross functional teams on large scale projects. Data management experience preferred.
License/Certification: Valid driver's license. Current state's RN license.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.