Job Description

Strong project management and organizational skills, with the ability to manage multiple priorities and meet regulatory deadlines.

In-depth knowledge of Utilization Management processes, prior authorization tools, and regulatory compliance requirements.

Strong communication and stakeholder engagement skills, with the ability to collaborate effectively with clinical, operational, regulatory, and leadership partners.

Proficiency in data analysis, reporting tools, and software used to track and communicate regulatory and operational information.

Ability to work independently with minimal direction while effectively navigating ambiguity and changing priorities.

An active RN license

The standard schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m.

Candidates must reside in Oklahoma.

This position supports Population Health and Clinical Operations (PHCO) and Medical Affairs.

Position Purpose: The Clinician Specialist provides clinical and operational support, guidance, and direction to the department related to utilization management and/or case management. The position is responsible to develop, implement, and monitor clinical documentation incorporated into clinical guidelines, policies, and/or procedures that will enable the department to meet and exceed goals, maintain regulatory compliance, improve quality, and promote overall efficiency and effectiveness related to clinical practices.

• Under the direction of departmental leadership and the Medical Directors, draft clinical guidelines in a standardized format to be utilized by department staff that align with departmental policies and procedures. This may including drafting (and/or creating new entries in the information system) new clinical criteria, as well as reviewing existing criteria for opportunities to modify and edit criteria as needed to ensure guidelines are up to date, and in compliance with state and federal guidelines.
• Monitor and organize the clinical-focused Department Standard Operating Procedure (SOP) and Policy & Procedures to ensure accuracy, creates new standard operating procedures as needed to facilitate compliance with state and federal regulations. Collaborates with Department leadership and Medical Directors to assist in development or modification of policies & procedures as needed.
• Oversee the modification or creation of member and provider letters, including determination notices and other regulatory notices, utilized by the department. Suggests and implements modifications as necessary to ensure regulatory compliance as well as improved efficiency. Collaborates with internal stakeholders to ensure impacted staff are educated on new policies, procedures, and processes to ensure successful implementation and compliance.
• Measure and evaluate effectiveness as it relates to current workflows and processes; compare measurement results to standards and work with the team to improve performance and close identified gaps.
• Research and identify industry best practices and other relevant available published information to contribute to the development of guidelines, policies, and procedures in order to achieve optimal clinical and/or operational outcomes. Develop and maintain documentation necessary to support consistent, operationally sound processes such as tip sheets, standard operating procedures, audit tools.
• Obtain data and/or run basic reports to determine department performance related to areas of focus, as directed by department leadership. Summarize data for casual analysis or create basic presentations order to communicate progress to management.
• Job performance requires fulfilling other incidental or related duties as assigned, including but not limited to collaborating with department trainer and supervisory staff in order to plan for implementations and roll out new policies and/or procedures, reviewing regulatory updates, and participating in a variety of department projects.

Education/Experience: MA/MS – Masters Degree preferred. 3-5 years related experience required.

For Clinical Specialist position in Medical Management: Experience with MCG clinical guidelines required.

Prior experience with MCG CareWeb QI guideline modification module preferred.

License/Certification: RN, LMSW, LCSW, LPC, or MHC License required.

For Clinical Specialist position in Medical Management: Licensure as RN required.

Pay Range: $70,100.00 - $126,200.00 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