Performance Monitor Specialist, Clinic

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

Key details: Centene is hiring a remote Performance Monitoring Specialist, Clinical, to join the Care Management clinical auditing team. In this role, you will audit care management member interactions by reviewing call recordings and related documentation to ensure compliance with organizational policies and contractual requirements. The ideal candidate is a Registered Nurse with a background in case management, excellent attention to detail, and experience evaluating clinical documentation and call quality.

• 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, step actions, and training materials as well as State Contracts when 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 all policies and standards

Education/Experience: Bachelor's Degree in Nursing, Clinical Social Work/Counseling required OR Associate's degree and an RN with 3+ years of clinical experience. 3+ years of experience in a clinical environment (inpatient or outpatient). 1+ year of experience in Managed Care (UM, BH, CM) preferred. Familiarity with Medicare and Medicaid programs preferred.

Licenses and Certifications: A license in one of the following is required: Licensed Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), or Licensed Marital and Family Therapist (LMFT). Certified Case Manager (CCM) preferred.

Pay Range: $56,200.00 - $101,000.00 per year