Centene Corporation

Project Manager

• Provide end-to-end project management support for Contact Center Telephony initiatives
• Focus on Interactive Voice Response (IVR) systems and related technology solutions
• Translate business needs into actionable plans
• Manage risks and dependencies
• Ensure smooth implementation of innovation and system improvements
• Lead change management efforts to support adoption and sustainment of new processes, enhancements, and telephony capabilities across the organization
• Manage the full project life cycle
• Create project plans and schedules
• Manage budget and facilitate project execution, deployment, and closure
• Partner with contact center operations, IT teams, vendors, and business units to oversee program implementations
• Support rollout activities and ensure smooth adoption of new IVR features or telephony tools
• Utilize corporate and industry standard project management tools and techniques
• Assist with establishment and maintenance of corporate project management methodology and other department procedures
• Maintain detailed project documentation including meeting minutes, action items, issues lists and risk management plans
• Provide leadership and communicate project status to all stakeholders and external agencies
• Negotiate with project stakeholders to identify resources, resolve issues, and mitigate risks
• Coordinate cross-functional meetings with various functional areas to meet overall stakeholder expectations and company’s objectives
• Provide functional and technical knowledge across multiple business and technical areas
• Monitor the creation of all project deliverables to ensure adherence to quality standards including design documents, test plans, training materials, and operations documentation
• Approximately 10% travel

Project Manager IV

Manager

• Manages a team of auditors and clinical professionals and is accountable for audit quality, consistency, and overall program performance for potentially preventable readmissions.
• Oversees payer readmission review programs to ensure accurate, compliant determinations and achievement of payment integrity objectives.
• This role directs the identification and validation of potentially preventable readmissions while supporting appropriate reimbursement under MS-DRG and APR-DRG methodologies.
• Responsible for driving program results through audit oversight, trend analysis, and the development of standardized review criteria and best practices.
• Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams to support the design, execution, and ongoing monitoring of readmission and DRG-related Payment Integrity strategies.
• Monitor program performance against defined metrics, financial targets, and operational benchmarks, using trend analysis to identify risks, variances, and opportunities for improvement.
• Provide leadership and operational oversight to teams performing readmission, MS-DRG, and APR-DRG reviews, ensuring accuracy, consistency, timeliness, and adherence to established review standards.
• Ensure compliance with federal and state regulations, managed care organization requirements, contractual obligations, and internal policies governing Payment Integrity and audit activities.
• Prepare and present reports, analyses, and performance summaries to leadership and key stakeholders, highlighting audit outcomes, trends, and actionable recommendations.
• Identify process gaps, operational risks, and control weaknesses, and implement or recommend corrective actions to improve quality, efficiency, and program effectiveness.
• Lead, coach, and develop team members by setting clear expectations, promoting accountability, and fostering a culture of collaboration, quality, and continuous improvement.
• Serve as a subject matter expert for Payment Integrity practices within assigned scope, providing guidance on readmission review methodology, audit standards, and reimbursement considerations.

Manager, Payment Integrity – Readmission

• Accountable for the Medical Loss Ratio (MLR) compliance and reporting program across assigned lines of business, ensuring accurate calculation, strong governance and controls, and timely submission of federal and state filings.
• Provides strategic and operational leadership for end-to-end MLR activities, including methodology oversight, documentation standards, audit readiness, rebate execution, and regulatory examinations.
• Leads and develops a team, sets priorities and deliverables, and drives cross-functional alignment with Finance, Actuarial, Legal/Compliance, Government Affairs, and operational partners.
• Serves as the escalation point for complex interpretation and judgment matters, proactively identifies and mitigates enterprise risk, and sponsors continuous improvement initiatives that strengthen data quality, consistency, and regulatory confidence.
• Provides oversight of the MLR reporting calendar and delivery model for assigned lines of business; set expectations, assign work, and ensure filings to CMS and state regulators are accurate, complete, and submitted on time.
• Provides oversight and final review of MLR methodology, assumptions, and classifications; ensure consistent application of federal and state requirements (e.g., ACA commercial markets, Medicare Advantage, Medicaid) and alignment with internal policy.
• Leads cross-functional forums and working sessions with Finance, Actuarial, Legal/Compliance, Government Affairs, and operations to drive decisions, resolve issues, and ensure clear ownership of actions that impact MLR results and regulatory posture.
• Designs, implements, and maintains MLR governance, internal controls, and documentation standards; approve key artifacts and ensure an audit-ready trail from data sources through final filing outputs.
• Oversees MLR performance monitoring and threshold management; interprets drivers, evaluates emerging risk, and sponsors mitigation strategies and corrective action plans in partnership with business owners.
• Has oversight of MLR rebate planning and execution, including governance over inputs, leadership approvals, and downstream communications to ensure compliance with federal and state requirements and timelines.
• Establishes a risk-based monitoring and review plan; oversees deeper-dive analyses, internal audits, and control testing; ensures remediation is implemented, validated, and sustained.
• Maintains awareness of legislative and regulatory changes impacting MLR; assess impact, advise leadership on options and risk, and lead implementation of required policy, process, and control updates.
• Maintains oversight of MLR-related policies, procedures, and tools (or their enterprise alignment); set standards for accurate classification of claims, quality improvement activities, and administrative expenses, and resolve interpretation disputes.
• Serves as the primary accountable leader for regulatory inquiries, audits, and examinations related to MLR; approve responses, ensure supporting documentation quality, and coordinate cross-functional participation.
• Coaches and develops team members; provides consultation and training to stakeholders on MLR requirements, controls, and risk management expectations.
• Provides executive-ready reporting and recommendations to senior leadership and governance committees on MLR compliance status, key risks, control effectiveness, and remediation progress.
• Contributes process improvement and data governance initiatives (e.g., standardization, automation, reconciliations, evidence retention) to improve oversight, efficiency, and consistency across the MLR lifecycle.
• Performs other duties as assigned. Complies with all policies and standards.

Senior Manager, Medical Loss Ratio

Vice President

• Responsible for the growth and performance of assigned mid/high complexity and revenue Medicare markets within a region
• Develop and execute market-specific strategies
• Foster cross-functional collaboration
• Develop strong internal and external partnerships with key stakeholders
• Drive operational excellence
• Manage P&L for assigned markets
• Develop market-specific strategic operating plans with KPIs, milestones, and governance processes
• Lead expansion and performance of value-based care initiatives
• Monitor and analyze the changing landscape and recommend strategies
• Drive quality initiatives aligned with STAR outcomes
• Provide effective leadership to direct and matrixed teams

Vice President, Medicare Market – Southeast

Operations

• Lead and direct process improvement initiatives by utilizing process improvement methodologies in the analysis of current operations and design of improvement projects across all areas that impact operations
• Support NCQA HEDIS audit readiness and compliance, ensuring accurate and timely submissions
• Lead daily audit readiness activities, including Roadmaps, Section 5 documentation, Measure Specifications, CAHPS coordination, and auditor engagement
• Oversee the administration, coordination and evaluation of quality assurance and training
• Direct the execution of performance improvement projects, including process mapping and process design including HEDIS audit timelines and deliverables
• Serve as primary point of contact for auditors and leadership, supporting audit communications and successful outcomes
• Create and maintain dashboards, communications, and strategies to improve effectiveness
• Research and develop best practices, policies, procedures, and goals in compliance with internal and external guidelines
• Oversee data analysis and gathering processes and programs to establish costs and benefits of process effectiveness and efficiency
• Ensure business unit is compliant with URAC and Joint Commission Accreditation standards
• Review and implement new technological tools and processes
• Establish strong collaborative relationships with all functional units and their leaders

Director, Quality & Process Improvement, HEDIS Audit

Pharmacist

• Act as a subject matter expert on complex pharmacy issues
• Respond to escalated calls from members, provider/physician's offices, and pharmacies
• Make outbound calls and enter pharmacy overrides into systems
• Take member/prescriber/pharmacist inquiry calls for benefit questions
• Offer options including submission of prior authorization requests
• Research issues and take appropriate action to resolve them
• Conduct inbound and outbound calls for claims resolution
• Assist team members in guiding them to appropriate resolution of inquiries
• Participate in training less experienced staff
• Act as a liaison between internal departments for data gathering and problem solving
• Present proposed solutions clearly
• Assist with audit preparation and special project work as assigned
• Comply with all policies and standards

Senior Pharmacy Resolution Specialist

Data Analyst

• Responsible for analytic data needs of the business unit
• Handle complex data projects and acts as a lead for other Data Analysts
• Provide advanced analytical support for business operations in various areas
• Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources
• Review data to determine operational impacts and needed actions
• Develop reports and deliverables and make recommendations to management
• Assist management in driving business decisions based on data
• Ensure compliance with federal and state deliverable reporting requirements by performing data quality audits and analyses
• Assist with training and mentoring other Data Analysts
• Performs other duties as assigned

Data Analyst IV, Provider Data, SQL

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
• 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

Therapist

• Performs clinical reviews of clinical therapy services and/or durable medical equipment to members based on service request assessments
• Provides clinical expertise based on practice standards
• Works with senior management to identify ways to improve the review and execution of therapy services based on clinical reviews of service request assessments
• Performs utilization reviews of service requests regarding specialty therapy services and/or durable medical equipment for members based on best practice and documentation standards by the national therapy associations and organizational policies
• Provides recommendations for therapy determinations and refers members to care management, as appropriate, based on service request assessments
• Works with Utilization and Care Management teams and healthcare providers to ensure members are receiving the appropriate care and treatment
• Expands therapy specialty knowledge and works with senior management to identify areas of improvement with therapy services and/or durable medical equipment for members
• Assists with providing education including developing clinical trainings, consultations, and guidance related to therapy authorizations and/or durable medical equipment
• Provides feedback to leadership on opportunities to improve the review and therapy services and/or durable medical equipment outcomes to members based on standards and organizational policies
• Performs other duties as assigned
• Complies with all policies and standards

Clinical Review Therapist – Physical Health

Data Scientist

• Lead the enterprise strategy for clinical data science, including predictive modeling, machine learning innovation, and causal evaluation of clinical programs.
• Develop and deploy advanced models that identify, stratify, and prioritize members for clinical and care management interventions.
• Oversee development of models for high-risk and rising-risk identification, avoidable utilization, chronic condition progression, and care management prioritization.
• Advance the organization’s AI capabilities by applying modern machine learning approaches, including deep learning and transformer-based models, to large healthcare datasets.
• Partner with clinical, operational, actuarial, and analytics leaders to translate business and clinical priorities into scalable data science solutions.
• Establish standards for model governance, monitoring, and performance management to ensure regulatory compliance, fairness, and responsible AI practices.
• Build, lead, and mentor a high-performing team of data scientists.

Senior Director, Clinical Data Science

Marketing

• Manage all activities related to marketing, communications, preventive health education and product- or market-specific consumer experience initiatives
• Provide strategic marketing and communications solutions to meet business objectives and timelines
• Oversee the writing, design and production of member and provider materials including newsletters, educational materials, handbooks, directories, manuals, member ID cards, promotional advertising, and website content while maintaining Corporate brand and style guidelines and state compliance requirements
• Own end‑to‑end AEP readiness and execution across assigned lines of business, materials, and workstreams, ensuring all outputs are delivered on time, accurate, and compliant with regulatory, operational, and business requirements, while serving as the single point of accountability for AEP delivery from intake through final fulfillment
• Lead, develop, and implement product and/or health plan strategic marketing plans, including traditional and non-traditional channels, community outreach, and related initiatives to grow and retain membership
• Oversee the development, coordination and production of marketing activities
• Develop strategic marketing measurement plans to effectively assess performance of marketing and communications activities
• Produce accurate and timely reports needed for contractual or business needs
• Identify department and project needs, with continuous development of process and procedures to drive effectiveness
• Build and maintain internal and external business relationships

Senior Manager, Marketing

Business Analyst

• Perform various analysis and interpretation to link business needs and objectives for assigned function
• Map provider source documents to directory outputs to ensure accurate data display
• Conduct Excel‑based reconciliation and validation of source‑to‑output data
• 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

Business Analyst II – Provider Data Operations

• responsible for managing, directing and supporting the dental operations for our Medi-Cal, Healthy Families and Medicare members.
• ensuring compliance with Department of Health Services (DHS) and Healthy Families MRMIB contracts.
• monitors Health Net's performance under its dental services contracts with the State.
• oversees Health Net's dental administration functions performed by the designated third party administrator.
• maintains and expands provider network through contract negotiations and execution.
• works closely with Dental Director to ensure that the dental care provided meets the standards for acceptable dental care.
• performs utilization review by reviewing claims and encounter data.
• develops and implements policies and procedures for the dental plan.
• assists in grievance resolution related to quality of care under the dental plan.
• actively participates in plan grievance procedures under the dental plan.

Dental Operations Manager

Chief Operating Officer

• Accountability for the day to day operations, profitability and growth
• Ensure that the customers' needs are well served
• Develop relationships with network providers, area employers, and contractors; ensure successful development and implementation of business plans
• Develop and implement strategic and tactical plans to ensure further growth and development of the business unit and ensure positive financial results
• Oversee development and execution of operating plans, including employee development, organization goals, and member and provider relations goals
• Establish criteria for measuring and assessing the success/performance of each component of operation
• Ensure appropriate provider network is developed and maintained
• Develop effective relationships with key stakeholders to educate providers and consumers on necessary topics
• Develop and establish operational mission statements, philosophy, policies, goals, objectives and strategy
• Provide management all necessary contractual requirement information regarding state and federal regulatory agencies

• 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.
• 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.