Centene Corporation

Therapist

• Manage populations of patients who meet high risk criteria in order to improve disease state outcomes and improve medication related safety
• Ensure safe, effective, and cost-effective medication therapy will be implemented for all patients in their care and monitor care appropriately
• Support quality department to improve HEDIS metrics on projects related to medication adherence and routine health visits
• Provide clinical recommendations pertaining to, but not limited to gaps in care, high risk medications, compliance and adherence, drug interactions, therapeutic substitution and generic substitution
• Utilize client formulary information and member specific benefits to guide appropriate medication recommendations
• Be aware of current and emerging clinical trends and educate clinical team, physicians and other prescribers
• Participate in the development of educational materials that may be presented as education intervention programs
• Collaborate with physicians and other prescribers by reviewing patients drug profiles to help safeguard against new prescriptions having unintended side effects and by working with prescribers to assure that the drugs prescribed are eligible for coverage; are low cost, high quality products
• Outreach to physicians to clarify medication regimens and make recommendations
• Conduct research and analysis to identify cost management and process/quality improvement opportunities

Clinical Pharmacist – Care, Medication Therapy Management

Compliance

• Serves as an individual contributor and subject matter expert responsible for supporting the day-to-day execution of the Medicare Compliance Advisory program in alignment with CMS requirements and applicable federal and state regulations
• Provides trusted advisory support to business and compliance leadership by providing regulatory guidance, conducting research and analysis, tracking issues, contributing to audit readiness and supporting compliance workplan activities
• Partners closely with the Sr. Manager, Medicare Compliance Advisory
• Execute the Medicare Compliance Program in alignment with CMS and applicable federal and state regulations, ensuring prevention, detection, and correction of noncompliance and FWA
• Execute assignments, ensuring timely, accurate, and well-documented completion of deliverables
• Serve as a compliance advisor and subject matter resource for Medicare programs by interpreting CMS regulations and guidance and translating requirements into clear, actionable business input; as well as advising leadership on compliance impact and implementation needs
• Support intake, tracking, and resolution of compliance issues, including documenting findings, assessing risk, and recommending corrective actions
• Contribute to monitoring and oversight activities by identifying regulatory risks and trends and supporting resolution of identified issues
• Prepare draft responses and supporting materials for regulatory inquiries, audits, data requests, and internal compliance reviews
• Maintain accurate and complete documentation of compliance activities, including issue logs, regulatory references, self-disclosures and supporting evidence
• Collaborate with cross-functional business partners to clarify regulatory requirements and support the implementation of compliant processes
• Escalate compliance risks, gaps, or delays in a timely manner to support effective risk management and decision-making
• Contribute to audit readiness by supporting documentation, process validation, and issue resolution activities
• Identify process improvement opportunities and support initiatives to enhance compliance controls, standardization, and operational efficiency
• Support compliance training and education initiatives, ensuring awareness of Medicare regulatory program requirements, standards of conduct, and reporting obligations.

Senior Compliance Administrator, Medicare Claims – Payment Integrity

Actuary

• Conduct analysis, pricing and risk assessment to estimate financial outcomes in support of the enterprise’s highest-priority Value-Based Care (VBC) initiatives
• Apply knowledge of mathematics, probability, statistics, principles of finance and business to calculate financial outcomes
• Support methodology development and refinement of valuation approaches used to measure program efficacy and shared savings
• Extract, clean, and analyze complex claims and clinical datasets to stand up valuation models end-to-end
• Ensure cash reserves and liabilities enable payment of future benefits
• Determines equitable basis for distributing money for insurance benefits
• Participate in merger and acquisition analysis
• Performs other duties as assigned
• Complies with all policies and standards

• Lead the Compliance Advisory & Research and Compliance Response & Escalation teams
• Providing strategic direction across complex compliance functions
• Partner closely with senior leadership to guide compliance research
• Oversee multi-market regulatory disclosures
• Help ensure key business initiatives align with applicable federal, state, and contractual requirements
• Support direct correspondence with state regulators
• Managing all facets of Compliance research for Medicaid line of business for the Enterprise
• Serve as senior leadership in Compliance Risk Assessment process
• Work closely with auditing and monitoring team, corrections team, and regulatory change management team to facilitate research and implementation
• Performs other duties as assigned

Senior Director, Medicaid Compliance

• Participates in corrections process for all lines of business
• Intakes and triages suspected issues of non-compliance
• Entry of compliance issues into GRC tool and assignment/coordination of issues to corrections team members
• Collaborates with compliance and business stakeholders to gather information, develop corrective action plans, identify and escalate barriers to progress and gather evidence of remediation
• Updates GRC tool to support corrections reporting
• Reviews and oversees progress towards remediation and documented key milestones in GRC tool
• Identifies issues that require escalation and ensures they are addressed timely through established paths and processes
• Conducts review of evidence to address root cause of issue and facilitate timely closure of issues
• Develops, implements and continually refines corrections reporting that provides meaningful trend analysis for business stakeholders and senior leadership on new, in progress and closed issues as well as regulatory sanctions
• Supports management in the development and maintenance of corrections processes and tools

Senior Compliance Corrections Specialist

Pharmacist

• Manage all aspects of pharmacy operations in two markets with multiple products
• Perform duties to develop, direct and implement a pharmacy benefit management program
• Aid in formulating and administering related organizational policies and procedures, including pharmacy service quality, pharmacy utilization management and achievement of Company goals for pharmacy and medical programs
• Establish the strategic vision, objectives and policies and procedures for the pharmacy program in support of the Corporate strategic vision for multiple plans and markets
• Plan, direct and implement pharmacy activities for multiple plans and products
• Act as the pharmacy contract administrator for the development and implementation of key contracts and ensure that relevant performance standards are met by vendors
• Participate in external accreditation initiatives for multiple plans and products
• Manage and analyze operating costs and participate in preparing materials needed for budget planning or special initiatives
• Generate, review and analyze drug utilization, utilization management, financial and other ad-hoc reports, records and directives
• Confer with staff to obtain data required for planning work function activities
• Review statistical analysis in support of recommendations and/or decision making for policies and operational procedures
• Maintain daily communication with plan management relative to each market and product
• Manage pharmacy department staff to assure adequate coverage and support in multiple locations and for multiple products
• Support provider education initiatives such as counter detailing and incentive programs in multiple markets

Senior Director, Pharmacy

Business Operations

• Provides first-line Enterprise Business Operations Services oversight of regulatory deliverables, reporting, and audit coordination
• Focuses on monitoring execution, identifying risks, and ensuring timely, accurate responses to regulatory and audit requirements
• Reviews and analyzes operational deliverables and data reports to ensure accuracy and timeliness of submission
• Owns end-to-end audit response activities, including initial evaluation of auditor requests
• Drives cross-functional leadership alignment to mitigate compliance risks and improve operational effectiveness
• Advises business stakeholders on new and emerging trends identified through regulatory reviews and audit results

Business Operations Oversight Analyst

• Define and develop standard and custom formularies for all lines of business including Commercial, Medicaid, Medicare Part D and the Health Information Marketplace
• Develop drug product review and formulary recommendations by assessing drug use trends, new drug releases and review of primary literature
• Analyze pharmacy cost of care, trends, and coordinate the development of appropriate use protocols and guidelines
• Set criteria for medication analysis, coordinate reports to clients, meet regulatory reporting requirements for drug utilization review and fraud and abuse reporting
• Develop clinical criteria for review of non-formulary or non-preferred drug lists medications and communicate recommendations to clients
• Develop and design clinical edits to adjudicate claims and enhance drug utilization
• Develop and review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
• Provide clinical guidance and support to the assigned pharmacy technicians
• Provide support documentation and develop communication for the Pharmacy & Therapeutic (P&T) Committee review process and decisions
• Performs other duties as assigned

Clinical Formulary Pharmacist

• leads a team providing advanced first-line oversight of regulatory reporting, audits, and risk management activities
• partners closely with leadership and business teams to assess regulatory impacts, monitor remediation efforts, and ensure sustainable, compliant operations
• provides strategic direction, oversight, and cross-functional guidance to ensure compliant, efficient, and scalable first-line oversight
• manages oversight of regulatory reporting and responses to state and federal inquiries in partnership with business stakeholders
• analyzes regulatory changes and advises senior leadership on impacts to business processes
• supports identification, analysis, and remediation of Archer findings and similar risk issues
• monitors key risk and compliance metrics and provides oversight of remediation progress
• oversees the development and execution of policies, procedures, and processes aligned to federal and state regulations
• evaluates systemic issues and ensures sustainable remediation strategies are implemented
• directs operational compliance audits and oversees development and execution of corrective action plans

Senior Manager, Business Operations Oversight

• Leads business case development for proposed initiatives
• Supports the strategic planning process
• Ensures initiatives support the strategic business plan and are executed well
• Leads larger scale, cross-functional initiatives to drive performance improvement
• Organizes work teams, drives consensus, and ensures policy/process integrity
• Performs detailed analysis of data, workflows, policies, etc.
• Writes and delivers communication to all levels of organization

Senior Business Process Consultant

• Assist in the development of Medicaid financial forecasts
• Provide technical support for projecting medical claims across many Medicaid markets
• Develop and analyze complex financial and statistical reports related to quality, cost, and effectiveness of healthcare services
• Prepare budget and forecast and analyze financial results related to expectations
• Assist with developing probability tables based on statistical analysis
• Analyze and evaluate required premium rates
• Assess cash reserves and liabilities for future benefits

Actuarial Analyst

Director

• Oversee service product lines
• Establish a profitable, disciplined organization that demonstrates a solid foundation for future growth
• Collaborate with local health plans and corporate service areas to set overall strategy for Managed Long-Term Services and Supports or MLTSS and Duals
• Oversee development of product extensions, capabilities and services that meet the needs of prospects and members
• Determine and implement the company’s product and service area expansion plans
• Develop and implement reporting and oversight infrastructure to ensure that MLTSS and Duals products are meeting financial, quality, and operational goals while remaining in full compliance with all regulatory requirements
• Implement tactics to launch MLTSS and Duals product lines in new states and partner with dual eligible product team as it relates to MLTSS
• Develop standard model for MLTSS and Duals products to be modified based on local regulations while maintaining core elements to create consistency of care
• Provide subject matter expertise to subsidiaries, corporate departments and external stakeholders with respect to MLTSS and Duals
• Lead organization to strong relationships with CMS and state Medicaid departments
• Build network of relationships with MLTSS and Duals experts to ensure knowledge flow of best practices to the local health plans and corporate departments
• Identify innovative new models and solutions to improve care, quality and cost efficiency
• Institute continuous improvement program for MLTSS and Duals product lines

Senior Director, Product Development – Innovation

• Coordinates the enterprise wide dual eligible strategy thru execution, implementation, innovation, policy, industry thought leadership to drive product lines growth of dual membership
• Participate in the development of strategic and business plans, and coordinate and communicate the enterprise duals strategy in partnership with the product organizations and markets
• Drive innovation by developing new models, partnerships and other competitive differentiators
• Develop and manage strategic projects to meet state and federal program objectives and regulatory requirements
• Assigns accountable parties and monitors outcomes
• Participate in the development of federal and state policy positioning for the product lines in collaboration with key internal/external stakeholders
• Facilitate and ensure regular, ongoing, and effective communications among shared service matrix partners, key contacts across the segment and enterprise as appropriate

Director, Duals Strategy

• Responsible for leading and managing the most complex, sensitive, and high-impact internal investigations across the organization
• Serves as a strategic advisor and subject matter expert on investigative best practices, regulatory compliance, and risk mitigation
• Independently evaluates and assesses allegations to determine whether domestic laws, regulatory policies, or internal policies, procedures, and standards have been violated
• Plans, scopes, and conducts complex, confidential internal investigations from inception to conclusion
• Conducts, manages, and documents interviews with witnesses, as required for investigatory purposes
• Identifies risks, interprets investigation results, and recommends and communicates remedial actions to mitigate future potential risks
• Performs follow up to ensure remedial / disciplinary measures are implemented appropriately and timely
• Plans, develops, leads, and manages multiple projects, including prioritizing and managing through execution
• Maintains meticulous case files and chronologies in accordance with best practices
• Communicates directly with Federal or State regulators
• Supports the development and maintenance of Corporate Compliance policies and procedures and workflows

Principal Compliance Investigator

Financial Planning and Analysis

• Provide leadership and oversight of all aspects of finance for the Business Unit
• Oversee all finance related activities for business unit including developing and monitoring progress against Annual Operating Plan
• Responsible for financial analysis, identification of month end financial drivers, and forecasting including headcount planning to ensure compliance with state requirements
• Responsible for identifying medical cost trends and leadership of medical cost improvement initiatives
• Perform financial impact analysis for new contracts and support negotiations
• Review monthly performance and financial results of the business unit and provide recommendations to senior management
• Responsible for the business unit’s contribution to corporate
• Perform duties as Chief liaison between Corporate Finance and the Business Unit
• Establish financial strategic vision, objectives, policies and procedures in support of the overall strategic plan
• Oversee and validate pricing models and lead initiatives to identify inefficiencies and areas of development and improvement
• Direct health plan analytical needs and coordinate reporting strategy
• Act as a lead for internal and external audits
• Lead rate setting activity and coordinate corporate and state actuaries
• Performs other duties as assigned
• Complies with all policies and standards.