RN Manager, Clinical Operations Oversight

Position Purpose: Lead the implementation and staffing oversight for audits of specific Utilization Management, Care Management Appeals activities within the organization. Provides guidance and oversight to 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 daily operations management and development of associates who monitor compliance through business monitoring audits, staff performance quality audits, surveillance and defect reports, and provides systemic report and education opportunities to executive leadership, departmental leaders and associates. Partners with senior leadership on the identification and implementation of business expansion opportunities.

- Ensures all operational processes are compliant with NCQA standards, as well as state and federal contract guidelines

- Coordinates monthly and quarterly audit and business monitoring results to provide systemic results and highlight opportunities for improvement

- Ensures team is operating at high standards with minimal overturn of results based on internal standards

- Coordinates with the Training team to ensure that training curriculum supports operational processes as defined in policies and procedures

- Implements audit programs to ensure compliance with all operational processes

- Reports audit results to management team and respective market leadership

- Supports operational departmental responses to individual market EQRO/State and CMS audits

- Oversees risk assessment of files for respective external audits

- Provides feedback to leadership team regarding audit results, opportunities for improvement, and/or required Corrective Action Plans

- Leads Monitoring Teams responsible for research, education and conducts audits

- 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

Education/Experience: Bachelor's Degree in Health Care related field, or related work experience required
5+ years of regulatory, audit, oversight or healthcare delivery required
Previous leadership, senior mentorship experience including responsibilities for hiring, training, assigning work and managing performance of staff required
Clinical licensure (RN) if managing team with RNs or LWCS/MSW LMHC licensure if leading team of Behavioral Health Professionals

Pay Range: $87,700.00 - $157,800.00 per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

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