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As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.

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What does it take?

What are the qualities that will help you achieve success in this role at Centene?

Success Profile

  • Detail-oriented
  • Trustworthy
  • Personable
  • Quick-thinking
  • Multi-tasker
  • Good listener

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Our Medical Roles

Clinical & Nursing Opportunities at Centene

Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.

Overall Medical Management

A member of the Centene Medical Management team, we innovate and execute strategies that redefine the industry standard for improving the lives and health of people.

Concurrent Review Nurse

To ensure our members get the best quality of care, you’ll assess acute member health conditions, treatment and intervention options, and match them with providers, community and health plan resources.

Prior Authorization Nurse

You’ll ensure our members get the best quality services, assistive devices, and equipment to promote optimal health and independence in the community and help promote health and independence.

Care Manager

Working directly with members, interdisciplinary care team, providers and data analytics, you’ll identify member health risks and conditions and intervention and service options.

LTSS Program Specialist/Program Specialist Field Based

Working directly with our most vulnerable members, you’ll identify individual member health risks and opportunities to enhance independence, quality of life and community engagement.

Referral Specialist

You’ll use our data systems to directly assist providers, requesting services and treatments for our members.

Medical Director

To help support the individual needs of members and develop programs that address issues, you’ll review population health data, help design clinical programs, and develop care delivery partnerships.

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Responsibilities

Job ID 1175674

Category Clinical & Nursing
Schedule Full-time
Description:
Position Purpose: The Clinical Reviewer performs medical record reviews to determine the quality of care; identifies quality issues and assures compliance with medical record standards and regulatory mandates; works collaboratively with Fidelis Care New York providers and educates them on all aspects of medical record review criteria including QARR/HEDIS; conducts member and/or provider telephonic outreach when needed.

Stays abreast to changes in Fidelis’ Performance Management measures and systems and changes in clinical guidelines.
Perform reviews of medical records and standards; post completed review reports with the number of records reviewed and quality issues noted.
Collaborate with providers and adhere to clinical standards of care to ensure appropriate outcomes; practice and adhere to departmental, state and national guidelines.
Educate providers on clinical guidelines and QARR/HEDIS measures.
Communicate in an efficient, effective, and friendly manner with providers, internal, and external staff.
Attend educational workshops; review professional publications; establish personal networks; participate in professional societies to maintain professional and technical knowledge.
Travel when required.
Qualifications:

Education/Experience: New York State RN or LPN License or FMG required. One year nursing experience, Clinical experience preferred. A minimum of one year HEDIS/QARR Medical record review and audit experience, required. Proficiency in Microsoft Office: Excel, Word,; Internet. Business Analysis Knowledge: Skilled to work in a fast paced environment. Must have strong analytical and problem solving skills. Ability to assess treatment needs and make recommendations that impact desired outcomes and quality of care. Customer Service: Skilled to communicate with all levels of management, internal and external customers. Ability to work well as a member of a team or alone. Effective Business Communication: Skilled in communicating with technical and business constituencies in writing effective business specifications and requirements. Requires proven ability to consistently meet and /or exceed goals. Must be capable of making commitments, setting priorities and delivering results on time.

License/Certification: New York State RN or LPN License or FMG required. Must have own transportation and valid driver's 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.
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Quote

“Centene is an exciting company to work for, the pace at which we’re growing allows numerous advancement opportunities. Also, we foster an environment that supports and offers numerous leadership growth opportunities.”

- Esmeralda Baig, SVP Operations, Complex Care Products

“I assisted with one of the Provider fairs in the community. Seeing how much we care for our community and our patients was very eye opening.”

- Julie Boulch, Director, Business Implementation Health Plan Initiatives

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Our Awards

Centene is consistently recognized for how well we treat our members, our people, and the communities we serve.

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Our Hiring Process

Learn more about our hiring process and discover other helpful information for applicants.

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“Flexibility is key. Centene is a company of change.”

Ashley Collier

Started as a Referral Specialist, now a Project Manager IV

See Ashley's career path

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