Centene Corporation

Communications

• Responsible for supporting the development and execution of executive communications and corporate messaging strategies
• Drafts communications including emails, intranet content, talking points, and speeches for senior executives
• Evaluates and helps manage internal and external engagement opportunities
• Manages and executes social media content (including LinkedIn) in alignment with defined strategy and guidance
• Partners with Corporate Communications to ensure executive messaging aligns with enterprise messaging frameworks and priorities
• Supports the dissemination and adoption of messaging tools across business units and functions
• Conducts research and develops supporting materials and proof points to reinforce key messages
• Partners with stakeholders to ensure messaging is actionable and relevant at the local and functional level

Director, Executive Communications, Corporate Messaging

Care Navigator

• Develops, assesses, and coordinates care management activities based on member needs
• Provides quality, cost-effective healthcare outcomes
• Educates members and their families/caregivers on services and benefit options
• Evaluates the needs of the member and recommends the plan for the best outcome
• Develops personalized care plans and identifies needed resources for care
• Provides psychosocial and resource support to members and caregivers
• Coordinates between members and care provider teams
• Collects, documents, and maintains all member information
• May perform on-site visits and provide education to care managers

Care Navigator – Foster Care

Supervisor

• Supervises the care management team and the care coordination of behavioral health members
• Monitors and reviews care management required documentation to maintain compliance
• Assigns caseloads to care management staff
• Works with senior management on escalated and complex care cases
• Educates and provides resources for care management team
• Evaluates care management team performance and provides feedback
• Provides coaching and guidance to care management team
• Monitors and review reports on a regular basis

Supervisor, Care Management – OB/NICU

Medical Director

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making
• Supports effective implementation of performance improvement initiatives for capitated providers
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Participates in provider network development and new market expansion as appropriate
• Assists in the development and implementation of physician education with respect to clinical issues and policies
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
• Develops alliances with the provider community through the development and implementation of the medical management programs
• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues
• Represents the business unit at appropriate state committees and other ad hoc committees
• May be required to work weekends and holidays in support of business operations, as needed

Network Engineer

• Perform day to day duties of assuring that providers are set up accurately in the provider information system
• Responsible for multiple state deliverables, network reporting and directories as well as claims payment resolution
• Provide support to external provider representatives to resolve provider data issues
• Research and effectively respond to provider related issues
• Act as the internal and external liaison for provider networking
• Maintain positive working relationships with participating physicians and groups
• Act as account manager for assigned groups
• Responsible for daily administration and operation of the contractual provider relationships

Senior Provider Engagement Network Specialist

Data Analyst

• Analyze integrated and extensive datasets to extract value, which directly impacts and influences business decisions.
• Work collaboratively with key business stakeholders to identify areas of value, develop solutions, and deliver insights to reduce overall cost of care for members and improve their clinical outcomes.
• Interpret and analyze data from multiple sources including healthcare provider, member/patient, and third-party data.
• Support execution of large-scale projects with limited direction from leadership.
• Identify and perform root-cause analysis of data irregularities and present findings and proposed solutions to leadership and/or customer.
• Manage multiple, variable tasks and data review processes under direct supervision within targeted timelines.
• Support the design, testing, and implementation of process enhancements and identify opportunities for automation.
• Support multiple functions and levels of the organization and effectively, both verbally and visually, communicate findings and insights to non-technical business partners.

Data Analyst I – Healthcare Analytics

Care Coordinator

• support Long Term Care (LTC) Care Coordination through activities such as member outreach and mailings, appointment scheduling and reminders, prescription coordination, and provider follow-up
• Works with senior care management team to support care management activities and the teams assigned to members
• Serves as a liaison alongside care managers and providers to ensure proper coordination of care for members
• Provides outreach to members via phone or home visits to engage members and discuss care plan/service plan
• Coordinates care activities based on the care plan/service plan and works with healthcare and community providers and partners
• Develops in-depth knowledge of care management services including responding to some complex or escalated issues
• Documents and maintains member records in accordance with state and regulatory requirements

Care Coordinator III

• Assists in developing, assessing, and coordinating holistic care management activities to enable quality, cost-effective healthcare outcomes
• May develop or assist with developing personalized service care plans/service plans for long-term care members and educates members and their families/caregivers on services and benefits available to meet member needs
• Evaluates the needs of the member, the resources available, and recommends and/or facilitates the plan for the best outcome
• Assists with developing ongoing long-term care plans/service plans and works to identify providers, specialist, and/or community resources needed for long-term care
• Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure identified services are accessible to members
• Provides resource support to members and their families/caregivers for various needs based on service assessment and plans
• Monitors care plans/service plans, member status and outcomes, as appropriate, and provides recommendations to care plan/service plan based on identified member needs
• Interacts with long-term care healthcare providers and partners as appropriate to ensure member needs are met
• Collects, documents, and maintains long-term care member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators
• May perform on-site visits to assess member's needs and collaborates with providers or resources, as appropriate
• Provides and/or facilitates education to long-term care members and their families/caregivers on procedures, healthcare provider instructions, service options, referrals, and healthcare benefits
• Provides feedback to leadership on opportunities to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner

LTSS Service Care Coordinator

Manager

• Develop, assess, and facilitate complex care management activities for primarily physical needs members
• Evaluate the needs of the member, barriers to accessing appropriate care
• Develop ongoing care plans/service plans and collaborate with providers
• Identify problems/barriers to care and provide appropriate care management interventions
• Coordinate between the member and care provider team to ensure adequate care
• Provide ongoing follow up and monitoring of member status
• Provide resource support to members and care managers for local resources
• Maintain compliance with current state, federal, and third-party payer regulators
• Facilitate education to members and their families on disease processes and healthcare benefits

Care Manager, RN – NICU

• Analyze integrated and extensive datasets to extract value, which directly impacts and influences business decisions
• Work collaboratively with key business stakeholders to identify areas of value, develop solutions, and deliver insights to reduce overall cost of care for members and improve their clinical outcomes
• Interpret and analyze data from multiple sources including healthcare provider, member/patient, and third-party data
• Support execution of large-scale projects with limited direction from leadership
• Identify and perform root-cause analysis of data irregularities and present findings and proposed solutions to leadership and/or customers
• Manage multiple, variable tasks and data review processes with limited supervision within targeted timelines
• Support the design, testing, and implementation of process enhancements and identify opportunities for automation
• Apply expertise in quantitative analysis, data mining, and the presentation of data to see beyond the numbers and understand how customers interact with analytic products
• Support multiple functions and levels of the organization and effectively, both verbally and visually, communicate findings and insights to non-technical business partners
• Independently engage with customers and business partners to gather requirements and validate results
• Communicate and present data-driven insights and recommendations to both internal and external stakeholders, soliciting and incorporating feedback when required

Data Analyst II – Healthcare Analytics

Clinician

• Provides clinical and operational support, guidance, and direction to the department related to utilization management and/or case management
• Develops, implements, and monitors clinical documentation incorporated into clinical guidelines, policies, and/or procedures
• Drafts clinical guidelines in a standardized format to be utilized by department staff that align with departmental policies and procedures
• Monitors and organizes the clinical-focused Department Standard Operating Procedure (SOP) and Policy & Procedures
• Collaborates with Department leadership and Medical Directors to assist in development or modification of policies & procedures
• Oversees the modification or creation of member and provider letters
• Collaborates with internal stakeholders to ensure impacted staff are educated on new policies, procedures, and processes
• Measures and evaluates effectiveness as it relates to current workflows and processes
• Researches and identifies industry best practices to contribute to the development of guidelines, policies, and procedures
• Develops and maintains documentation necessary to support consistent, operationally sound processes

Clinician Specialist

Pharmacist

• Audit prior authorization activities
• Identify opportunities for process improvement
• Support clinical training initiatives
• Help maintain the integrity of critical pharmacy systems and data
• Partner with business groups to identify and resolve errors in data and reporting
• Assist with the administration of audit processes and tools related to prior authorizations, appeals, quality improvement, star measurement reviews, inter-rater reliability and data entry
• Assess training needs and identify, select or develop appropriate training programs including training aids and materials
• Assist with training staff in the use of audit tools and identification of patterns or trends that require additional training or corrective action
• Maintain records of training activities and employee progress
• Participate in Quality and Advisory committees or provider education meetings

Clinical Audit Coordinator, Pharmacy

Business Analyst

• Perform various analysis and interpretation to link business needs and objectives for assigned function
• Detailed reviews of both state specific and corporate Payment policies for Compliance and Governance ensuring policies are accurate and up to date with guidelines
• Review, analyze, and interpret coding, reimbursement, and regulatory guidelines to ensure organizational compliance and payment integrity
• Develop, implement, and maintain Payment Policies, reimbursement methodologies, and claims editing logic to support accurate claims adjudication
• Monitor, report on, and track regulatory, coding, and policy updates, ensuring timely implementation and communication of changes across impacted stakeholders
• Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems
• Identify and analyze user requirements, procedures, and problems to improve existing processes
• Perform detailed analysis on assigned projects, recommend potential business solutions and assist with implementation
• Identify ways to enhance performance management and operational reports related to new business implementation processes
• Develop and incorporate organizational best practices into business applications
• Lead problem solving and coordination efforts between various business units
• Assist with formulating and updating departmental policies and procedures
• Complies with all policies and standards.

Business Analyst II – Policy Review

• Perform various analysis and interpretation to link business needs and objectives for assigned function
• Responsible for payment integrity repository updates and ensuring it remains up to date and accurate
• Review, analyze, and interpret coding, reimbursement, and regulatory guidelines to ensure organizational compliance and payment integrity
• Develop, implement, and maintain Payment Policies, reimbursement methodologies, and claims editing logic to support accurate claims adjudication
• Monitor, report on, and track regulatory, coding, and policy updates, ensuring timely implementation and communication of changes across impacted stakeholders
• Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems
• Identify and analyze user requirements, procedures, and problems to improve existing processes
• Perform detailed analysis on assigned projects, recommend potential business solutions and assist with implementation
• Identify ways to enhance performance management and operational reports related to new business implementation processes
• Develop and incorporate organizational best practices into business applications
• Lead problem solving and coordination efforts between various business units
• Assist with formulating and updating departmental policies and procedures
• Performs other duties as assigned
• Complies with all policies and standards

Business Analyst II – Coding

• Perform various analysis and interpretation to link business needs and objectives for assigned function
• Ensuring our internal claims coding editors remain accurate, up to date, and compliant
• Review, analyze, and interpret coding, reimbursement, and regulatory guidelines to ensure organizational compliance and payment integrity
• Develop, implement, and maintain Payment Policies, reimbursement methodologies, and claims editing logic to support accurate claims adjudication
• Monitor, report on, and track regulatory, coding, and policy updates, ensuring timely implementation and communication of changes across impacted stakeholders
• Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems
• Identify and analyze user requirements, procedures, and problems to improve existing processes
• Perform detailed analysis on assigned projects, recommend potential business solutions and assist with implementation
• Identify ways to enhance performance management and operational reports related to new business implementation processes
• Develop and incorporate organizational best practices into business applications
• Lead problem solving and coordination efforts between various business units
• Assist with formulating and updating departmental policies and procedures
• Performs other duties as assigned