绩效监控专员，诊所
Performance Monitor Specialist, Clinic
职位职责：负责临床文件评估，识别改进的月度见解，并参与评分者间一致性会议。协助持续开发审查工具以确保标准的有效性，并在合同和护理模式标准内适当记录预期临床表现的证据。
关键信息：Centene 正在招聘一名远程绩效监控专家（临床），加入护理管理临床审计团队。在此职位中，您将通过审查电话录音和相关文件来审核护理管理成员互动，以确保符合组织政策和合同要求。理想的候选人是一名注册护士，具有病例管理背景，具备出色的关注细节能力，并有评估临床文档和电话质量的经验。
- 按照要求审查临床文档，进行临床文件评估，以确保符合必要的临床合规性。
- 参与临床审查工具的开发和持续审查，以确保临床要素准确反映所需绩效标准。
- 在需要时审查项目描述、政策和程序、步骤操作以及培训材料，以及州合同，以评估审查工具要素、部门流程、员工培训和合同/部门标准的一致性。
- 利用临床知识和经验评估会员健康评估、临床需求和干预措施的记录，以满足合规标准。
- 参与讨论审查结果、改进机会及改进建议的会议。
- 在临床文件审查中发现的问题区域进行适当升级。
- 根据需要参与州、CMS 和 NCQA 审计的准备工作，收集和/或审查相关的临床领域。
- 达到既定的生产力和 IRR 标准进行文件审查。
- 遵循部门指南和流程。
- 其他指派的任务。
额外职责：
- 执行其他指派的任务
- 遵守所有政策和标准
教育/经验：需要护理学学士学位，或临床社会工作/咨询学士学位，或副学士学位加注册护士资格及3年以上临床经验。在临床环境（住院或门诊）中3年以上经验。有管理护理经验（授权管理、心理健康、病例管理）1年以上优先。家庭
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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
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
Originally posted on Himalayas