Centene Corporation

Customer Support

• Serves as the first-line advocate focusing on resolving inquiries, issues, or concerns for members and/or providers
• Leverages a variety of communication channels to provide timely, accurate, and personalized support on routine complaints
• Receives and responds to routine member and/or provider inquiries, requests and/or concerns
• Maintains performance and quality standards based on established contact center metrics
• Provides customer service in a high pace contact center environment over the phone, via live chats and emails
• Documents member or provider information and communications for quality and performance tracking

Customer Service Advocate I – Spanish Bilingual

Solutions Engineer

• Plans, coordinates, develops, and supervises of all activities related to the integration of data and analytics solutions to meet the business requirements of the organization
• Creates and integrates data architecture guidelines, standards, and common services to support project integration requirements
• Performs other duties as assigned
• Complies with all policies and standards

Senior Manager, Solutions Architecture

Therapist

• Perform utilization review of authorization requests regarding specialty therapy services for members
• Assist with training and network management support for therapy providers
• Perform detailed review of therapy service requests based on evidenced based practice
• Refer members to case management as appropriate based on service request assessment
• Provide clinical recommendations for any adverse therapy determination
• Provide clinical expertise based on shared practice standards regarding sub-specialty therapy practice to peers
• Provide support for specialty therapy providers, including assistance with clinical trainings

Utilization Specialty Therapist

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 claims, provider data, member data, clinical data, HEDIS, pharmacy, external reporting
• Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources
• Review data to determine operational impacts and needed actions; elevate issues, trends, areas for improvement and opportunities to management
• Develop reports and deliverables and make recommendations to management
• Model data using MS Excel, Access, SQL, and/or other data ware house analytical tools
• Assist management in driving business decisions based on data
• Ensure compliance with federal and state deliverable reporting requirements by performing data quality audits and analysis
• Assist with training and mentoring other Data Analysts
• Assist with determining work load and related activities for other Data Analysts

Data Analyst IV, Quality Strategy

Call Center Representative

• Oversees and offers guidance around current contact center operational processes to establish operational targets, best practices, and training programs that support service, quality, and efficiency standards
• Supports contact center staff with day-to-day oversight and resources for contact center operations
• Oversees daily operations of contact center teams by planning, directing, and evaluating team performance to ensure customer satisfaction, compliance, and standards
• Monitors interactions, workflow, and metrics of the contact center to ensure adherence to performance, quality, and efficiency standards
• Serves as primary point of contact for contact center and operations employees and resolves complex issues
• Manages and maintains policies, procedures, and regulations to ensure compliance requirements are achieved
• Provides training and coaching to direct reports for operational improvement within the contact center
• Evaluates contact center operations team on performance and provides feedback on improvement opportunity and career growth path
• Collaborates with training teams to develop, review, and approve of appropriate training materials and/or programs for contact center operations team members
• Supports contact center operations senior management with onboarding, hiring, and training new employees, recent promotes, and transfers to department
• Performs other duties as assigned
• Complies with all policies and standards

Supervisor, Contact Center Operations

Director

• Oversee efforts to improve provider network performance and promote provider engagement.
• Oversee the planning and operations of all activities related to provider network performance.
• Collaborate with health plans and various stakeholders to develop overall plan for improving provider performance.
• Develop effective training and communication tools and processes related to provider network performance.
• Provide direction to determine company-wide analytic reporting needs and provide training and support on network performance applications and reporting tools.
• Collaborate with health plan leaders and providers to review network performance, including quality, cost, care gaps, and risk adjustment gaps, and develop improvement plans.
• Oversee provider profiling and network performance analytic support functions and provide support to health plans and other stakeholders.
• Oversee the evaluation of provider Health Benefits Ratio (HBR), quality, unit cost and utilization trends and identify and implement network improvement opportunities.
• Oversee the support and improvements of existing application tools to enhance outcomes and functionality.

Director, Provider Network Performance

Procurement

• Lead and support contract negotiations
• Work with business, procurement management and legal through the contracting process
• Develop and execute Request for Information and Request for Proposals (RFI, RFP) to gain understanding of market dynamics and supplier’s position within the market
• Lead tactical negotiations on small impact contract, with support on strategy, technique and messaging
• Connect with internal customers to identify business needs and develop scope of project
• Understand and communicate SS&P goals and objectives and how the standard strategic sourcing process supports these goals and objectives
• Performs other duties as assigned
• Complies with all policies and standards

Strategic Sourcing Specialist I

Compliance

• Participates in the oversight of WellCare's and/or its delegated subcontractor's corporate ethics and compliance program
• ongoing oversight and analysis of regulatory compliance issues
• conducting focused reviews and audit
• oversight, and monitoring of activities to assess compliance with WellCare's contractual and regulatory requirements
• collaborates with business owners and/or delegated vendors to drive remediation and assist WellCare and delegated subcontractors to maintain integrity through oversight and monitoring and in meeting Government-sponsored health care program requirements
• assists in the assessment of new and amended Government-sponsored health care program contracts and requirements
• prepares accurate and timely formal written reports on oversight and monitoring activity findings and recommendations and ensure workpapers are properly prepared

Compliance Oversight Specialist – Non-Clinical

Account Manager

• Manages third party program relationships with Delegation partners for performance management standards
• Acts as the critical link between our Delegation partners and internal Departments
• Provides direct Account Management responsibilities including scheduling regular meetings with delegated entities
• Maintains regular communications with leads at Delegated CM entity and works internally to communicate plan needs
• Ensures that payments are accurate and timely for care management services rendered

Vendor Relations Manager

• Manage Specialty Therapy and Rehabilitation Services (STRS) clinical services including management and marketing of clinical services
• Manage clinical services including oversight of clinical policies and procedures and day-to-day operation
• Oversee the provider outreach and training activities pre and post implementation
• Ensure compliance with established initial and concurrent review, referral, and authorization policies, procedures and processes
• Ensure all programs and clinical operations are in full compliance with state and federal regulations, including HIPAA
• Ensure payer contract clinical deliverables are met
• Monitor the effectiveness of existing procedures and outreach/intervention efforts and ensure full compliance with physical, occupational, speech, and home health scope of practice state guidelines
• Analyze data, monitor trends and recommend potential quality improvement opportunities including provider issues, service gaps, member needs
• Ensure accurate and timely reporting to health plan partners on authorizations, denials, appeals, provider outreach, call center metrics, and utilization trends to include analytics and interventions
• Performs other duties as assigned
• Complies with all policies and standards

Manager, Specialty Therapy – Rehabilitation Services

Backend Engineer

• Responsible for analytic data needs of the business unit
• Handle complex data projects and act as a lead for other Data Analysts
• Provide advanced analytical support for business operations
• 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
• Model data using MS Excel, Access, SQL, and/or other data warehouse analytical tools
• Assist management in driving business decisions based on data

Data Analyst IV, Python, Snowflake

• Manage and implement strategies to ensure successful maintenance and implementation of compliance programs
• Ensure all Medicare and Medicaid product and services are being tested for compliance with program regulations
• Maintain and track laws and regulations, contract documentations, amendments, and various compliance measures
• Develop policies, procedures, and process to comply with federal program regulations
• Provide guidance to various departments regarding compliance issues
• Conduct compliance audits, develop and implement corrective action plans
• Perform plan risk assessments and report emerging trends, deficiencies and variances
• Provide required Ethics, Compliance, Risk Management, FWA, privacy, and security training

Senior Manager, Ethics & Compliance – Internal Audit

Human Resources

• Support and perform human resources related transactions and business processes to ensure timely and accurate data based upon system workflow and business requirements
• Complete HR related business process transactions including data entry tasks for new hires, job/employee changes, organizational changes, transfers, terminations, and creating/closing positions within Workday HCM
• Perform routine audits and checks of data to ensure accuracy and make applicable corrections
• Work with HR Business Partners, People Leaders and/or other partnering teams to gather requirements for revisions to HR related processes, analyze impact, and implement process changes
• Assist in the testing, implementation, upgrading and support of new or modified system changes
• Serve as a departmental resource and troubleshoot unusual data entry issues and collaborate with the customer on updates
• Develop simple HR related reports
• Serve as a backup to HR Services team
• Perform Tier I support for Workday Learning related tasks

HRIS Specialist, Workday

• Train provider staff on the Company’s clinical philosophy and evidence based practice methods
• Review Provider Profiling Reports with STS Provider Staff to identify and report compliance with contract requirements and identify areas for improvement
• Assist STS Providers in developing corrective action plans
• Audit Provider charts and facilities to gather quality information
• Develop and provide formal Provider Staff Trainings
• Develop core “basic training” package required of Providers in each of the Company’s Markets
• Participate in cross functional teams to solve system issues
• Identify Provider System needs and propose solutions

Clinical Provider Trainer – Specialty Therapy Services

Business Analyst

• Perform or assist with regulatory filings for medium/high risk states
• Completes Qualified Health Plans (QHP) federal and/or state required application templates
• Guides and conducts special projects; reviews and provides interpretation of application instructions from regulatory agencies
• Assists in the development of and implementation of auditing and monitoring strategies
• Performs root cause analysis to inform continuous improvement
• Oversees and prepares Qualified Health Plan templates and/or formal regulatory filing documents
• Audits QHP documents for high-risk states ensuring compliance and accuracy
• Actively manages and collaborates with Sources of Truth (SOT) document owners
• Attends and represents their Regulatory Operations team in meetings
• Analyzes proposed and/or enacted federal and state legislation and/or regulatory orders
• Communicates impacts and/or risks related to their Regulatory Operations team
• Leads implementation of passed legislation or new regulations impacting Qualified Health Plan (QHP)
• Takes ownership of team activities for the maintenance, implementation and continuous improvement of department policies, procedures, and work processes
• Assists with managing relationships with regulatory agencies
• Leads onboarding of new employees and training of analysts on essential job duties
• Coordinates and leads projects internal to the department