Remote Utilization Review Rn Jobs in Rochester Hills, MI

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.

**This role requires up to 75% local travel to support members in Wayne and Macomb counties. Applicants have the flexibility to work remotely from their home the remaining time. We provide all required equipment and reimburse for mileage at the current IRS rate. The schedule is Monday - Friday, 8am - 5pm.**

Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families.

• Evaluates the needs of the member, barriers to accessing the appropriate care, social determinants of health needs, focusing on what the member identifies as priority and recommends and/or facilitates the plan for the best outcome
• Develops ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources to address member's unmet needs
• Identifies problems/barriers to care and provide appropriate care management interventions
• Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services
• Provides ongoing follow up and monitoring of member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs
• Provides resource support to members and care managers for local resources for various services (e.g., employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans, as appropriate
• Facilitate care management and collaborate with appropriate providers or specialists to ensure member has timely access to needed care or services
• May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
• Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators
• Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits
• Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner
• Other duties or responsibilities as assigned by people leader to meet business needs
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 - 4 years of related experience.
License/Certification:

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required

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