Centene Corporation

Medical Director

• Serves as the LTSS subject matter expert, leading RFP development and submissions while supporting the design, implementation, and growth of LTSS programs
• Directs the long-term care of members with physical/medical health needs and/or behavioral/mental health needs to develop and assess high quality, cost-effective healthcare outcomes
• Develops strategies and objectives within long-term care management to improve member and/or provider experience
• Provides leadership to the development, implementation, monitoring, and ongoing improvement of the long-term care management process
• Sets goals and objectives for long-term care management team and oversees care management data and reporting metrics to achieve quality and cost-effective healthcare results and working with senior leadership
• Leads long-term care management policies and procedures within the care management team to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards
• Oversees and monitors work assignments and caseloads of long-term care management staff based on state requirements, care management staff experience, and member needs
• Monitors, reviews, and signs off on contract required reporting as required

Director, LTSS Clinical Care Management

Director

• Oversee activities of the provider contracting, network development and/or provider relations functions and aid in formulating and administering organizational policies and procedures
• Oversee provider contracting activities to ensure efficiency and maintain compliance with the business unit’s policies and standards, government laws and regulations
• Implement development activities for the recruitment and contracting of provider networks in new and prospective markets, and existing market expansions
• Support new business launch in diverse markets while considering individual market circumstances, provider community, budgeting constraints and available resources
• Perform complex financial analyses to identify medical cost improvement opportunities, develop strategies to reach financial goals, and execute contracting strategies to meet goals and objectives
• Oversee contracting and network development staff and external consultants in the development of provider networks for new and expansion markets
• Monitor performance, develop, and implement business solutions to address process and quality gaps, and communicate network strategy and planning
• Ability to travel

Director, Contracting & Network Development

Manager

• Assists in developing, assessing, and coordinating holistic care management activities to enable quality, cost-effective healthcare outcomes
• Develops personalized service care plans/service plans for long-term care members and educates members and their families/caregivers on services and benefits available
• Evaluates the needs of the member, resources available, and recommends/facilitates the plan for the best outcome
• Assists with developing ongoing long-term care plans/service plans and works to identify providers, specialist, and community resources needed
• Coordinates as appropriate between the member and/or family/caregivers and the care provider team
• Provides resource support to members and families/caregivers for various needs
• Monitors care plans/service plans, member status and outcomes, and provides recommendations based on identified member needs
• Interacts with long-term care healthcare providers and partners
• Collects, documents, and maintains long-term care member information
• Performs home and/or other site visits to assess member’s needs
• Provides and/or facilitates education to long-term care members and their families/caregivers

LTSS Service Care Manager

Clinician

• Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards
• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
• Communicates with members, providers, facilities, and other departments regarding appeals requests
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
• Works with leadership to increase consistency, efficiency, and appropriateness of responses of all appeals requests
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Clinical Review Clinician – Appeals

Project Manager

• Plans, organizes, monitors, and oversees projects utilizing cross functional teams
• Support the full project life cycle including requirements gathering, creation of project plans and schedules
• Obtaining and managing resources, managing budget
• Facilitating project execution, deployment and closure
• Negotiate with project stakeholders to identify resources, resolve issues, and mitigate risks
• Monitor the creation of all project deliverables to ensure adherence to quality standards

• Develops, assesses, and facilitates complex care management activities
• Evaluates the needs of the member and recommends appropriate care
• Develops ongoing care plans and collaborates with providers
• Identifies problems and provides care management interventions
• Coordinates care between members, caregivers, and care provider teams
• Provides ongoing follow-up and monitoring of member status

Care Manager, RN

Account Executive

• Represent the company to all prospective and existing clients
• Monitor client satisfaction and recommend changes to enhance satisfaction
• Perform sales and marketing related activities on company programs and products, including infusion services, medical supplies, respiratory supplies, and retail pharmacy services
• Serve as the contact for client issues and inquiries and collaborate with various departments on resolutions ensuring clients needs are met
• Develop and maintain relationships with various levels of clients utilizing current network for additional accounts
• Monitor client satisfaction and recommend appropriate strategies, tactics, and operational initiatives to continuously enhance client satisfaction
• Attend patient care conferences and professional in-services to ensure continuance of new products and strategies
• Assist with account renewals, contract negotiations and intake referral process

Account Executive II – Specialty Pharmacy

• Develops, assesses, and facilitates complex care management activities for primarily mental and behavioral health needs members
• Evaluates the needs of the member via phone or in-home visits related to the resources available, and recommends and/or facilitates the care plan/service plan for the best outcome
• May perform telephonic, digital, home and/or other site visits outreach to assess member needs and collaborate with resources
• Develops ongoing care plans for members with high level acuity and works to identify providers, specialists, and community resources needed for care
• Monitors care plans/service plans and/or member status and outcomes for changes in treatment side effects, complications and clinical symptoms
• Provides education to members and their families on procedures, healthcare provider instructions, treatment options, referrals, and healthcare benefits

Care Manager

Financial Planning and Analysis

• Direct, negotiate and handle activities of the business units finance, accounting and analysis functions.
• Responsible for leading the G&A function.
• Oversee the preparation of accurate and timely financial reports ensuring requirements are met.
• Lead G&A function.
• Interpret financial reports for management team.
• Review, communicate, and present strategic plans, operating budgets and forecasts.
• Provide financial plan for performance variances, operating alternatives, program and investment initiatives.
• Monitor and analyze business processes and systems to ensure data and system integrity.
• Determine targets and measures ensuring alignment with business unit and corporate objectives, evaluate effectiveness and recommend updates as needed.
• Serve as the point of contact for corporate and business unit functions regarding financial matters.
• Direct support activities and timely information related to sales and account management to drive profitability.
• Ensure optimization and accurate reporting of various financial related matters.

Senior Director, Finance

General

• Supports community connection activities including connecting members to community resources to support their care management journey and provide necessary care resources in a cost-effective manner
• Provides members with known community resources and supports the care team to identify member community support and provide health education as appropriate
• Processes support to members to connect them to known community and care resources in a cost-effective manner
• Supports the coordination of community outreach resources available to members and promotes awareness of care/services
• Serves as support for members on community and care resource inquiries and opportunities available to members
• Supports all member related correspondence and educational materials to assist in the facilitation of a successful community connection
• Documents and maintains all community resources to ensure standards of practice and policies are in accordance with health plan requirements
• Provides assistance to the clinical team of nurses and social workers
• Conducts non-clinical general health assessments in order to refer members to appropriate care/services, resolve concerns on member’s behalf, and gather information for medical providers and staff working within the organization
• Conducts non-medical assessments such as home safety, assessment of the community/environment resources, transportation, employment, and others to be able to refer to appropriate care/services, resolve concerns on member’s behalf, and gather information for medical providers in staff working within our organization
• Conducts telephonic and/or in-person outreach to locate individuals and families in the community who are hard to reach
• May make visits to individual homes and/or community organizations
• Working Knowledge of Social Determinants of Health (SDOH) barriers
• Performs other duties as assigned
• Complies with all policies and standards

Community Resource Coordinator II

• Oversee and manage the functions of the quality improvement program
• Providing support to staff and communicate with departments and staff to facilitate daily quality improvement (QI) functions
• Review and analyze reports, records and directives
• Confer with staff to obtain data such as new projects, status of work in progress, and problems encountered, required for planning work function activities
• Verify data to be submitted in accordance with government program requirements and ensure compliance with state, federal and certification requirements
• Prepare reports and records on work function activities for management
• Oversee the review and analysis of reports
• Evaluate current procedures and practices for accomplishing the assigned work functions objectives to develop and implement improved procedures and practices and to ensure compliance with required standards
• Collaborate with appropriate departments to document, investigate and resolve formal or informal complaints and appeals in accordance with Company and State policies, procedures and requirements
• Monitor and analyze costs and participate in the preparation of the budget

Manager, Quality Improvement

Care Coordinator

• Works with care management team on administrative care management activities including performing outreach, answering inbound calls, and scheduling services
• Serves as a point of contact to members, providers, and staff to resolve issues and documents member records in accordance with current state and regulatory guidelines
• Provides outreach to members via phone to support with care plan next steps, community or health plan resources, questions or concerns related to scheduling, and ongoing education for both the member and provider throughout care/service
• May apply in-depth knowledge of assigned health plan(s) activities and resources
• Serves as the front-line support on various member and/or provider inquiries, requests, or concerns which may include explaining care plan procedures and protocols
• Applies in-depth knowledge of care management support activities including care plans and community resources
• Supports member onboarding and day-to-day administrative duties including sending out welcome letters, related correspondence, and program educational materials to assist in the facilitation of a successful member/provider relationship
• Works with care management team on escalating requests and inquiries to management
• Documents and maintains non-clinical member records to ensure standards of practice and policies are in accordance with state and regulatory requirements and provide to providers as needed
• May support training of new hires
• Performs other duties as assigned
• Complies with all policies and standards

Care Management Support Coordinator III

Psychologist

• Authorize, direct and monitor care for behavioral health and/or substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care
• Conduct peer reviews with psychologists, behavioral health therapists and/or Board Certified Behavior Analysts for outpatient services and/or psychological testing requests
• Interact with network practitioners to provide education on best practice models and utilization management processes
• Interact with the Medical Director, or designee, to discuss clinical authorization questions and concerns regarding specific cases
• Respond to state, provider, and member complaints related to psychological testing or other services requiring review by a PhD/PsyD
• Facilitate outpatient rounds offering clinical input and oversight related to outpatient services
• Performs other duties as assigned. Complies with all policies and standards.

Psychologist Reviewer

• 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