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Supervisor, Clinical Grievance and Appeals​/RN

Job in Raleigh - Wake County - NC North Carolina - USA
Full Time position
Listed on 2021-02-25
Job specializations:
  • Healthcare
  • Nursing
    RN Nurse, Utilization Review Nurse
Job Description & How to Apply Below
Position:  Supervisor, Clinical Grievance and Appeals (RN)
Position Purpose:

Supervise nurses in a highly regulated department responsible for performing medical necessity case reviews for appropriateness of medical care and service.
Supervise the day to day clinical operations and functions within the department, ensuring productivity and quality metrics are met.
Provide oversight and interpretation of state/federal regulations and NCQA standards impacting member appeals and grievances from a clinical perspective. Ensure that the clinical Appeals and Grievance department processes all cases in accordance with policies and procedures
Utilize clinical expertise to serve as a resource to the team regarding escalated or complex clinical issues
Monitor and distribute team’s caseload and ensure adequate coverage
Monitor and evaluate performance standards and provide feedback and guidance or problem resolution.
Identify and develop opportunities for process improvement and work with various leaders to ensure problems are corrected
Train and onboard new team members
Audit staff to standards and provide continuous feedback
Assist management in committee work, regulatory audits and regulatory reporting.
Analyze and interpret state and federal regulatory requirements and NCQA standards and provide guidance to team to ensure adherence
Position Requirements
Bachelor, 3 to 4 Years work experience
Education / Experience: Bachelor's degree in Nursing preferred. 3+ years of combined nursing and appeal and grievance, or utilization management or case management experience. Previous supervisory experience strongly preferred. Proficient with Microsoft Office applications. Knowledge of coding preferred. Previous Quality Improvement experience preferred. Knowledge of DHCS/DMHC regulations preferred.

**This position is office based therefore; candidates must be located in Raleigh or surrounding area**


Licenses/Certifications: RN required.


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.
Required Language Skills:
  • English - Very good
Additional Information / Benefits
Are you ready to advance your career? Well, look no further. WellCare of North Carolina is rapidly growing and has several openings we urgently need to fill, and we want you to join us. Your innovative thinking and new ideas can help us change the world of healthcare and transform our communities.

Why should you apply?
• Very competitive benefits package
• Generous Paid Time Off
• Excellent growth and advancement opportunities
• Bonus program
• And many more….

Don’t miss this great opportunity, APPLY today! All referrals are also welcome.

Supervisor, Clinical Grievance and Appeals (Job ID: 1217094) - (Please contact us using the "Apply for this Job Posting" box below)
Contact Information
Contact Name: Centene Corporation
Contact Phone: 512-406-7208
Preferred method of contact: Email with CV via Application Box below.
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