Company: Centene Corporation
Posted on: December 20, 2019
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
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
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
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
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
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: Licensure as 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.
Keywords: Centene Corporation, Tonawanda , Clinician Specialist, Other , Tonawanda, New York
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