Centene Corporation

Manager

• Oversee and monitor the performance of both internal and external cost recovery and cost containment initiatives according to targeted project metrics and forecasted recovery and cost avoidance goals for each Health Plan
• Manage internal and external vendors cost avoidance and cost recovery initiatives
• Partner with health plans to identify and contain cost through collaboration with national vendors for each recovery category
• Develop annual budget and projected target for each national vendor and assist them with achieving projected annual savings
• Evaluate and streamline existing processes and implement new processes to reduce costs
• Present trends and cost containment opportunities, recommend action plans, and assist with the implementation of those plans
• Assist health plans in understanding the rules, regulations and processes around cost recovery
• Monitor other departments’ performance and processes and evaluate for cost recovery
• Compile and Present reporting packages for Senior Management on current cost avoidance and cost recovery initiatives

Senior Manager, Payment Integrity – Vended Audit Programs

Business Intelligence Developer

• Leads the technical efforts to create Enterprise-class data assets that provide business insight
• Produces reports and performs meaningful quantitative or qualitative analyses addressing impactful business issues
• Combines reports with subject-matter expertise to deliver coherent and insightful takeaways
• Leads development efforts of BI solution architecture that translates business requirements to technology solutions
• Oversees execution of business analysis activities to fulfill strategic business needs
• Delivers complex project setups, analysis, data flows, designs for customers
• Collaborates with end users to identify needs for improved data process efficiency

Lead Business Intelligence Engineer

• Provide case management and service coordination to members living with mental illness and/or substance abuse disorders
• Evaluates member service needs and develops or contributes to development of care plans/service plans
• Acts as liaison and member advocate between the member/family, physician, and facilities/agencies
• Supports members with primarily mental/behavioral health needs
• Performs frequent home and/or other site visits
• Provides and/or facilitates education to long-term care members and their families/caregivers
• Provides coordination of service authorization to members and care managers for various services
• Ensures appropriate referrals based on individual member needs
• Maintains accurate documentation and supports the integrity of care management activities in the electronic care management system
• Provides feedback to leadership on opportunities to improve and enhance quality of care and service delivery

Care Manager – Mental Health, Psychiatric RN

Auditor

• Perform internal audits, including the execution of information technology, strategic, operational, financial, and compliance risk-based audits
• Execute risk-based audits evaluating controls and processes for scalability, effectiveness, efficiency, and risk mitigation strategies
• Assist in audit planning, refinement of audit work programs, and wrap up of engagements
• Assist in drafting audit reports that summarize audit findings and recommendations
• Develop and communicate audit observations, recommendations, process improvement opportunities, and best practices and obtain management responses
• Monitor and report on the status and findings of audits
• Assist audit team in performing special projects and implementing internal audit best practices
• Performs other duties as assigned

IT Internal Auditor II

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 claims, provider, member, and encounters data
• Identify and assess the business impact of trends
• Develop, maintain, and troubleshoot complex scripts and reports developed using SQL, Microsoft Excel, or other analytics tools
• Contribute to the planning and execution of large-scale projects with limited direction from leadership
• Assist in the design, testing, and implementation of process enhancements and identify opportunities for automation
• 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 and thrive in a demanding, quickly changing environment
• Demonstrate a sense of ownership over projects and ask probing questions to understand the business value of tasks
• 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
• Partner cross-functionally at all 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
• Provide technical guidance to junior analysts

Data Analyst III – Healthcare Analytics, Medical Economics

Medical Director

• Provide medical oversight, expertise and leadership to ensure the delivery of cost effective, quality healthcare services to health plan members.
• Serves as clinical advisor to and educator of medical management staff.
• Provide leadership and expertise in the development, implementation and interpretation of medical review and quality related policies and guidelines.
• Provide oversight and direction for staff and provider training and education.
• Promote positive relations with the local medical community.
• Review case management data, identifies trends and gaps in care and recommends corrective actions.
• Review all quality of care issues and oversees the development and implementation of processes for improvement.
• Monitor performance indicators to ensure the delivery of cost-effective care within quality standards.
• Monitor member and provider satisfaction and recommends and implements changes to improve satisfaction levels.
• Work collaboratively to develop corporate clinical care standards and medical practice policies.
• Provide medical guidance to the Medical Management department.

Chief Medical Officer

Account Manager

• Maintain and strengthen partnerships between the health plan and the contracted Behavioral Health provider networks serving our communities
• Serve as a strategic consultative liaison ensuring delivery of the highest level of care to our members
• Engage with providers to align network performance opportunities and solutions, and consultative account management and accountability for issue resolution
• Drive optimal performance incentive performance, quality, and cost utilization
• Serve as primary contact for providers and act as a liaison between the providers and the health plan
• Receive and effectively respond to external provider related issues
• Completes special projects as assigned
• Ability to travel locally 2-4 days a week
• Complies with all policies and standards
• Conducts regular in-person and virtual visits with Behavioral Health physicians to provide real-time support for Claims, Credentialing, and Care Management, UM, Network, and Compliance
• Educate providers regarding policies and procedures related to referrals, claims submission, credential documentation, self-service tools, websites, Electronic Health Records, Health Information Exchange, and Electronic Data Interface
• Investigate, document, and drive resolution of Behavioral Health provider concerns, ensuring timely follow-up and clear communication
• Receive, triage, and resolve provider-related issues in coordination with internal partners including claims, credentialing, care management, utilization management, network, and compliance
• Build and sustain collaborative, solution-oriented partnerships that enhance provider satisfaction and network stability
• Ensure effective escalation and tracking of issues through closure
• Translate complex claims and utilization data into clear, actionable insight for providers and internal stakeholders
• Partner with analytics, finance, and operations teams to ensure data accuracy and alignment
• Perform other duties as assigned

Provider Engagement Account Manager – Behavioral Health

Machine Learning Engineer

• Manages the design and development of scalable software solutions utilizing statistical, artificial intelligence (AI), and machine-learning (ML) modeling approaches
• Performs and oversees research and testing to develop machine learning algorithms and predictive models
• Conducts and reviews model training and evaluation
• Integrates, tests, tunes, and monitors solutions
• Leads the design, development, and maintenance of predictive analytics, machine learning, and artificial intelligence solutions, making specific determinations about overall performance, reliability, and scalability
• Collaborate with multiple partner teams such as Business, Technology, Product Management, Legal, Compliance, Strategy and Business Management to develop use cases and to deploy solutions into production
• Communicates advanced ML/AI concepts to senior leadership to facilitate decision making
• Works cross functionally with product managers, data scientists, and engineers to understand, implement, refine, and design machine learning and other algorithms
• Maintains knowledge of new learning approaches, technology, and tools through continuous research to ensure currency of solutions
• Drives innovative ideas and act as one of the thought leaders in identifying and selecting use cases for applicability of machine learning, appropriate modeling techniques and technologies, and determines success criteria and implementation methodologies
• Manages the hiring and training of new and existing staff, conducts performance reviews, and provides leadership, technical guidance, and coaching
• Shares knowledge and develops staff capabilities to strengthen understanding of business issues and best practices
• Develops and communicates organizational objectives; inspires and motivates team members to achieve results
• Responsible for the establishment and maintenance of Agile Scrum ceremonies and methodologies on the team
• Performs other duties as assigned
• Complies with all policies and standards

Senior Manager, Machine Learning – Fraud, Waste and Abuse

• Provide medical oversight, expertise and leadership to ensure the delivery of cost effective, quality healthcare services to health plan members
• Serves as clinical advisor to and educator of medical management staff making sure correct clinical judgment is applied to all medical management determinations
• Provide leadership and expertise in the development, implementation and interpretation of medical review and quality related policies and guidelines
• Provide oversight and direction for staff and provider training and education
• Promote positive relations with the local medical community, including periodic consultation with providers or prescribers
• Review case management data, identifies trends and gaps in care and recommends corrective actions
• Review all quality of care issues and oversees the development and implementation of processes for improvement
• Monitor performance indicators to ensure the delivery of cost-effective care within quality standards
• Monitor member and provider satisfaction and recommends and implements changes to improve satisfaction levels
• Work collaboratively to develop corporate clinical care standards and medical practice policies
• Provide medical guidance to the Medical Management department

DevOps Engineer

• Collaborate with cross-functional teams to proactively monitor, maintain, and enhance production systems.
• Bridge the gap between software development and IT operations, with an emphasis on incident triage, systems operations and documentation, business user support and communications, toil reduction, work automation and improving the reliability of services.
• Provide timely and accurate user support/troubleshooting as well as management of escalations within enterprise SLA’s (Service Level Agreements).
• Researches and analyzes enrollment/provider data and Utilization Management/Case Management business processes to support applications issues while acquiring a more advanced skill set for assistance of product design and solutions.
• Perform On Call post deployment application validations of enhancement/code fixes and monitoring for escalations.
• Act as a key player in application incident management, ensuring prompt detection, triage, and resolution of production incidents.
• Monitor and manage technology business cycle processing within the application environment.
• Establish, document, and refine incident management processes to reduce downtime and service degradation.
• Participate in post-incident reviews, ensuring that lessons learned are incorporated into operational practices and automation efforts.
• Develop, improve and review runbooks and documentation and keep them up to date to ensure consistency across SRE teams.
• Document operational processes including workflows, system configurations, troubleshooting guides, and incident reports to improve the team’s ability to respond quickly to incidents and system failures.
• Review and provide feedback and process improvement recommendations on topics like automation, monitoring gaps, toil reduction and systems resiliency.
• Comply with all policies and standards.

Site Reliability Operations Analyst II

Security Engineer

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Customer Service Advocate III

Compliance

• Assist in maintaining Centene Corporation’s Compliance Program
• Provide regulatory interpretation, perform compliance reporting, lead special projects
• Develop and implement compliance auditing and monitoring strategies
• Respond to external requests for information required by the organization for its regulatory filings
• Manage compliance reporting responsibilities and respond to inquiries from state and federal regulatory agencies
• Manage ethics and compliance projects or implementations
• Review and synthesize regulatory requirements and create policy and/or position statements
• Assist in managing annual code of conduct attestation and remediation
• Communicate state and federal requirements to internal and external clients
• Provide development guidance and assist in the identification, implementation, and maintenance of compliance policies, procedures and work instructions
• Assist in the identification, analysis, and resolution of compliance issues
• Maintain and review regulatory documentation necessary to maintain corporate standards
• Assist in developing, producing and conducting compliance training programs
• Perform periodic compliance audits, risk assessments and conducts related to ongoing compliance monitoring activities
• Assist health plans in managing relationships with regulatory agencies and seek to resolve policy issues which may negatively impact service to members
• Assist management with interim health plan compliance officer responsibilities
• Plan, direct and coordinate the implementation of Compliance Committee policy to ensure decisions are properly executed
• Serve as a company-wide resource and liaison on policies, contract issues and provisions, communications, workflow, and quality improvements initiatives

Senior Compliance Analyst

Medical Billing and Coding

• Codes, abstracts and analyzes inpatient and/or outpatient medical records using the most current International Classification of Diseases, Tenth Revision (ICD-10) for CMS risk adjustment purposes.
• Always coding to the highest level of specificity.
• Follows the Official ICD-10 guidelines for Coding and Reporting.
• Follows CMS risk adjustment guidelines.
• Understands the impact of ICD-10 codes on the CMS HCC risk adjustment model.
• Ability to meet productivity and accuracy standards.
• Ability to defend coding decisions to both internal and external audits.
• Performs other duties as assigned.
• Complies with all policies and standards.

Risk Adjustment Coder

Operations

• Provides enterprise leadership and strategic oversight for benefit and provider payment configuration
• Ensures claims configuration, authorization and payment requirements, benefit rules, pricing logic, and system alignment enable compliant, efficient, and scalable claims processing
• Aligns operational execution with regulatory requirements, financial integrity, and enterprise strategy
• Establish and execute the enterprise strategy for claims configuration operations
• Serve as the accountable business owner for claims configuration platforms and pricing systems
• Ensure configuration complies with CMS, state Medicaid agencies, Marketplace requirements, and contractual obligations
• Drive continuous improvement to reduce claims payment errors and rework
• Lead and develop high-performing configuration operations teams

Senior Manager, Payment Integrity – Vended Audit Programs

Lead Business Intelligence Engineer

Care Manager – Mental Health, Psychiatric RN

IT Internal Auditor II

Data Analyst III – Healthcare Analytics, Medical Economics

Chief Medical Officer

Provider Engagement Account Manager – Behavioral Health

Senior Manager, Machine Learning – Fraud, Waste and Abuse

Chief Medical Officer

Site Reliability Operations Analyst II

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Customer Service Advocate III

Senior Compliance Analyst

Risk Adjustment Coder

Vice President II – Configuration Operations