Centene Corporation

Manager

• Provide leadership and direction for continuous quality improvement initiatives
• Improve efficiency, processes, quality of care, and services
• Provide and analyze reports to identify trends and opportunities
• Lead national HEDIS audit and submission activities, including Measure Specifics, HOQ, IDSS, PLD, XML, benchmarking, and final submission
• Coordinate company-wide quality assessment and improvement activities
• Oversee and coordinate annual file audits and other quality-related initiatives
• Manage and implement work tools, processes, reports, and audit tools
• Recommend quality improvement opportunities and develop and implement solutions with management, the Quality Improvement Committee, and other committees
• Provide feedback to rectify errors and prevent further inconsistencies
• Oversee monthly and quarterly reports and data to identify trends, improvement opportunities, and interventions
• Maintain policies and operating procedures aligned with internal and external guidelines

Senior Manager, Quality Improvement, HEDIS Audit

• Provide strategic, operational and administrative support to the Population Health and Clinical Operations Executive of the California market
• Gather information and initiate action plans on topics, issues and projects impacting PHCO operations and strategic initiatives
• Collaborate with senior leadership to achieve results and complete deliverables
• Identify departmental and cross-functional opportunities and objectives and develop action plans
• Monitor action-plan portfolios, coordinate assigned action items, report progress, and help resolve issues and risks
• Develop and coordinate Executive communications and change-management activities
• Develop presentations and align key messages across audiences
• Prepare and organize Executive staff meetings and track meeting action items and follow-ups
• Manage agendas, minutes, calendars, and meeting materials
• Coordinate management, risk, and mitigation updates for California health plan leadership
• Attend enterprise and functional meetings as the Executive representative and identify impacts, risks, and interdependencies
• Oversee the Executive external meeting schedule, agendas, attendees, and presentation materials
• Accompany the CEO to key meetings and coordinate follow-up activities
• Manage special Executive projects or committees
• Support strategic planning activities, meetings, information, and presentations
• Serve as liaison between Executive Leadership and teams and represent Executive plans and actions

Strategy & Planning Manager – CA Market

Data Analyst

• Provide advanced analytical support for business operations in areas including claims, provider data, member data, clinical data, HEDIS, pharmacy, and 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 for management
• Model data using MS Excel, Access, SQL, and/or other data warehouse analytical tools
• Ensure compliance with federal and state deliverable reporting requirements through data quality audits and analysis
• Assist with training and mentoring other Data Analysts
• Handle complex data projects and act as a lead for other Data Analysts
• Perform other duties as assigned
• Comply with all policies and standards

Data Analyst III

Communications

• Apply and uphold brand standards across creative deliverables
• Partner with stakeholders to understand business objectives and develop creative briefs and communication materials
• Design, produce, and edit multimedia assets for internal and external communications, including digital, video, print, presentations, and web-based content
• Coordinate creative projects from intake through delivery
• Prioritize work, manage timelines, and communicate project status
• Collaborate with internal teams and external vendors
• Track project milestones, dependencies, and deliverables using project management tools
• Assist with production schedules and resource coordination across multiple projects
• Improve creative processes and workflows
• Review deliverables for accuracy, quality, brand consistency, and legal and regulatory compliance
• Support communication and feedback among stakeholders, creative teams, and external partners
• Perform other duties as assigned
• Comply with all policies and standards

Creative Production – Communications Manager

Business Analyst

• Perform analysis and interpretation to link business needs and objectives for the assigned function
• Support business initiatives through data analysis, identify implementation barriers, and conduct user acceptance testing
• Identify and analyze user requirements, procedures, and problems to improve existing processes
• Perform detailed analysis on multiple projects, recommend business solutions, and ensure successful implementations
• Enhance performance management and operational reports related to new business implementation processes
• Coordinate with business units and departments to develop and deliver training programs
• Develop, share, and incorporate organizational best practices into business applications
• Diagnose problems and identify opportunities for process redesign and improvement
• Formulate and update departmental policies and procedures
• Serve as the subject matter expert on the assigned function product
• Perform other duties as assigned

Business Analyst III

Executive Assistant

• Relieve the executive of administrative functions to increase availability for senior-level responsibilities
• Foster executive partnerships
• Manage calendars
• Handle stakeholder interactions
• Proactively solve problems
• Communicate and interpret administrative and operating policies and procedures
• Prepare and coordinate operational records, statistics, and reports
• Gather information and coordinate logistics for board meetings, programs, events, and conferences
• Arrange facilities and caterers, issue invitations, coordinate speakers, prepare materials, and assist with event budgets
• Handle clerical and administrative situations and conflicts
• Manage confidential and time-sensitive material
• Prepare routine and advanced correspondence, including letters, memoranda, and reports
• Comply with all policies and standards
• Perform other duties as assigned

Patient Care

• Work with members and providers to close care gaps and remove barriers to care
• Improve member and provider experience through outreach and face-to-face interaction
• Collaborate with providers in the field to improve HEDIS measures
• Educate provider practices on HEDIS measures and HEDIS ICD-10/CPT coding
• Support quality improvement interventions and audits related to plan providers
• Assist in resolving deficiencies affecting compliance with State and Federal HEDIS standards
• Conduct telephonic outreach and health coaching to members
• Conduct face-to-face education with members and families in provider offices
• Schedule doctor appointments and arrange transportation and follow-up appointments
• Connect members with community-based resources and affinity programs
• Act as liaison and member advocate between members/families, physicians, and facilities/agencies
• Serve as WellCare representative in embedded provider offices
• Assess provider performance data and identify opportunities for improvement
• Collaborate with Provider Relations on Quality, Risk Adjustment, Operations, claims, and encounters
• Document all member-related contact actions
• Interact with customer service and other departments to resolve member issues
• Refer members to case or disease management as appropriate
• Complete special assignments and other duties as assigned
• Comply with all policies and standards

Patient Care Advocate

• Work with members and providers to close care gaps, remove barriers to care, and improve member and provider experience
• Conduct outreach and face-to-face interaction with members and providers at large IPA and/or group practices
• Collaborate with providers in the field to improve HEDIS measures
• Provide education on HEDIS measures and coding
• Support quality improvement interventions and audits related to plan providers
• Assist in resolving deficiencies affecting plan compliance with State and Federal HEDIS standards
• Conduct telephonic outreach while embedded in provider offices
• Educate members about identified care gaps during medical appointments
• Schedule doctor appointments on behalf of practitioners and members
• Arrange transportation and connect members with community-based resources and affinity programs
• Maintain confidentiality of business and protected health information
• Act as liaison and member advocate between members/families, physicians, and facilities/agencies
• Represent WellCare in the provider community
• Advise and educate provider practices on HEDIS measures and HEDIS ICD-10/CPT coding in accordance with NCQA requirements
• Assess provider performance data and identify opportunities for improvement
• Collaborate with Provider Relations on Quality, Risk Adjustment, Operations, claims, and encounters
• Conduct face-to-face member and family education regarding care gaps and barriers to care
• Conduct telephonic outreach and health coaching
• Arrange transportation and follow-up appointments
• Document all member contact actions
• Interact with departments including customer service to resolve member issues
• Refer members to case or disease management as appropriate
• Complete special assignments and projects
• Perform other duties as assigned
• Comply with all policies and standards

Vice President

• Oversee the product development function
• Formulate product vision and strategy
• Define future product needs and enhancements
• Drive creation of profitable, highly engaging, easy-to-use products across all business units
• Develop and oversee the model for managing product development strategy
• Develop and oversee the product roadmap in alignment with company strategic goals, market trends, competitive landscape, client, and consumer needs
• Drive digital and data/analytics product innovation
• Partner with strategic business unit leadership and portfolio management to plan and manage complex priorities and resources
• Build an effective and efficient product organization, including product management, consumer engagement, strategic partnerships, and innovation
• Drive efficiency within RFP and client implementation processes
• Review market landscape, analyze product usage, and review business cases and key metrics to ensure ROI
• Monitor and measure product competitiveness and support new business opportunities
• Manage, measure, and monitor strategic partners
• Perform other duties as assigned

Vice President – Product Strategy

Care Coordinator

• Develop, assess, and coordinate holistic care management activities for quality, cost-effective healthcare outcomes
• Develop or assist with personalized service care plans for long-term care members
• Educate members and families/caregivers about available services, benefits, procedures, instructions, referrals, and healthcare options
• Evaluate member needs and available resources, recommending or facilitating appropriate care plans
• Identify providers, specialists, and community resources for long-term care
• Coordinate between members/families/caregivers and care provider teams to ensure services are accessible
• Provide resource support for employment, housing, participant direction, independent living, justice, and foster care needs
• Monitor care plans, member status, and outcomes, recommending updates based on identified needs
• Interact with long-term care healthcare providers and partners
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Perform on-site visits and face-to-face assessments as needed
• Provide feedback to leadership to improve quality of care and service delivery cost-effectively
• Perform other duties as assigned

LTSS Service Care Coordinator

Medical Director

• Lead analytic service delivery by aligning strategic objectives with tool and capability development and deployment of analytic teams
• Lead advanced population health analytics, outcomes measurement, and managed care value analyses
• Support market engagement, pre-request-for-proposal strategy, and data-driven proposal development
• Direct planning and execution of enterprise-wide analytics projects and strategic initiatives
• Translate business goals into actionable analytics solutions
• Provide senior leadership support and partnership between business and technical partners
• Interface with leadership to communicate strategic intent to analytic teams
• Prioritize team work and manage executive customer expectations and relationships
• Align team goals and resource deployment with strategic objectives and the needs of multiple health plans and corporate stakeholders
• Serve as a primary domain contact, escalation point, and accountability owner for customer partnership and satisfaction
• Collaborate with leaders across analytic domains to align business needs and co-develop analytic solutions
• Mentor, manage, and continuously develop leaders and analysts

Director, Healthcare Analytics

Director

• Oversee development and implementation of contracting activities in network development and enhancement
• Provide strategic leadership, direction, and oversight of provider contracting, network development, and network optimization initiatives across multiple product lines
• Develop and execute network strategies supporting organizational growth, regulatory compliance, network adequacy, affordability objectives, and provider engagement goals
• Collaborate with executive leadership and cross-functional stakeholders to develop contracting solutions and strengthen provider partnerships
• Direct evaluation, review, negotiation, and ongoing management of product-specific contracts and amendments between the health plan and vendors
• Develop strategies for new networks with business development and providers to meet network access and unit cost objectives
• Determine resources and assemble teams across business functions
• Develop budgets aligned with Centene network management and financial objectives
• Support new business launches in diverse markets
• Lead network development specialists during implementation and development stages
• Monitor performance and implement solutions addressing process and quality gaps
• Communicate network strategy and planning to senior management and Centene leaders
• Negotiate complex and major provider contracts as needed

Senior Director, Contracting & Network Development

Risk

• Support the identification and assessment of operational, regulatory, compliance, and initiative-level risks
• Assist with analysis of data to identify risk trends, control gaps, and emerging risk indicators
• Support documentation of risks, mitigation strategies, and remediation action plans
• Partner with business owners and project teams to gather risk-related information and support control assessments
• Assist in implementing and maintaining risk management processes and internal controls within Enterprise Business Operations Services
• Prepare routine risk reports, dashboards, and metrics using established frameworks
• Perform other duties as assigned
• Comply with all policies and standards

Operational Risk Analyst

Investigator

• Conduct comprehensive reviews of medical records and documents supporting provider, supplier, pharmacy, and behavioral health claims
• Provide investigative support to the Special Investigations Unit on coding and billing issues
• Identify potential overpayments and suspected healthcare fraud, waste, and abuse
• Verify service authorizations and documentation against claim information
• Ensure the appropriateness and accuracy of diagnosis and procedure codes
• Coordinate medical necessity and level-of-care determinations with Medical Directors
• Validate services against CMS and state-specific coverage, limitations, and exclusion guidelines
• Coordinate with internal and external resources to determine code appropriateness in administrative, medical, claim, and financial records
• Develop reports of findings and recommendations
• Communicate complex audit results in meetings and/or judicial hearings
• Assist SIU investigators during provider, supplier, and pharmacy interviews, discussions, and negotiations
• Perform retrospective and prepayment medical-record reviews
• Investigate and analyze provider billing patterns to determine payment
• Prepare findings summaries and recommend next steps for providers
• Identify preventive measures and recommend policy, procedure, and provider-practice changes
• Collaborate with investigators to identify abuse and fraud using clinical and coding expertise
• Perform other duties as assigned
• Comply with all policies and standards

Clinical Investigator – Behavioral Health

Compliance

• Assist in maintaining Centene Corporation’s Compliance Program
• Provide regulatory interpretation and perform compliance reporting
• Lead special projects
• Develop and implement compliance auditing and monitoring strategies
• Respond to external requests for information required for regulatory filings
• Manage compliance reporting and respond to state and federal regulatory agency inquiries
• Manage ethics and compliance projects or implementations
• Review and synthesize regulatory requirements and create policy or position statements
• Assist with annual code of conduct attestation and remediation
• Communicate state and federal requirements to internal and external clients
• Develop, implement, and maintain compliance policies, procedures, and work instructions
• Identify, analyze, and resolve compliance issues
• Maintain and review regulatory documentation
• Develop, produce, and conduct compliance training programs
• Perform compliance audits, risk assessments, and ongoing monitoring activities
• Assist health plans with regulatory agency relationships and policy issues
• Assist management with interim health plan compliance officer responsibilities
• Coordinate implementation of Compliance Committee policy
• Serve as a company-wide resource and liaison on policies, contracts, communications, workflow, and quality improvements
• For Pennsylvania Health & Wellness, manage FWA risk and trend tracking, coordinate cross-functional fraud workflows, ensure regulatory compliance, lead the monthly fraud workgroup, submit the quarterly MCO FWA report, and liaise with DHS Bureau of Program Integrity and the OAG

Senior Manager, Quality Improvement, HEDIS Audit

Strategy & Planning Manager – CA Market

Data Analyst III

Creative Production – Communications Manager

Business Analyst III

Executive Assistant

Patient Care Advocate

Patient Care Advocate

Vice President – Product Strategy

LTSS Service Care Coordinator

Director, Healthcare Analytics

Senior Director, Contracting & Network Development

Operational Risk Analyst

Clinical Investigator – Behavioral Health

Senior Compliance Analyst