Centene Corporation

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 Compliance Analyst

• 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 responsibilities and respond to 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 with 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 periodic compliance audits, risk assessments and ongoing compliance monitoring
• Assist health plans in managing relationships with regulatory agencies and resolving 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, contract issues, communications, workflow and quality improvement initiatives
• For Pennsylvania Health & Wellness only: Track and identify non-compliance and fraud, waste and abuse risks and trends
• Convene operational leaders to ensure compliant end-to-end provider and member workflows
• Ensure FWA prevention, detection and recoupment processes comply with regulatory mandates and the CHC Agreement
• Lead the monthly PHW fraud workgroup and quarterly MCO FWA report submission
• Serve as a PHW liaison to the DHS Bureau of Program Integrity and the OAG

Program Manager

• Plan and deliver strategic programs and complex, large-scale enterprise-wide projects
• Lead large-scale, cross-functional healthcare migrations for implementation or process improvement
• Oversee program planning, management, and execution, including scope, schedule, and budget
• Create comprehensive timelines and ensure appropriate project deliverables
• Coordinate project managers and business analysts managing individual workgroups
• Create executive-level dashboards, project status updates, and post-implementation analytics reports
• Create and deliver best-practice and training information and collaborate on training materials
• Prepare and deliver documents for Program Steering Committees and executive teams
• Assess program risks, escalate issues, and manage risks, budgets, forecasts, and dependencies
• Conduct strategic analysis of business and operational opportunities
• Serve as the first escalation point for project issues and risks
• Create risk mitigation plans and communicate business and technology issues and solutions

Program Manager IV – Clinical Technology Operations

• Conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, interviews, data analytics, and other investigative resources
• Analyze, document, and maintain investigative activities, findings, recommendations, and outcomes
• Review claims, medical records, provider billing practices, enrollment information, financial records, and other documentation for potential fraud, waste, abuse, overpayments, or compliance concerns
• Prepare investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties
• Collaborate with business partners, compliance, legal, provider and payment integrity teams, and external agencies
• Support corrective actions, recoveries, audits, overpayment identification and recovery, regulatory responses, special projects, and program integrity initiatives
• Monitor emerging fraud schemes, billing irregularities, and healthcare program risks and recommend appropriate actions
• Support case progression through onsite audits, visits, drive-by activities, and interviews
• Comply with all policies and standards and perform other duties as assigned

Special Investigation Unit Investigator

Supervisor

• Manage workflow and activities related to investigation, review, resolution, recovery, and settlement of complex claims issues and Revenue Cycle Management
• Supervise daily tasks and workflow of the recovery and revenue cycle management team
• Ensure performance standards are met
• Monitor, evaluate, and communicate business process changes to the team, including aging review meetings
• Investigate and respond to escalated or complex issues
• Assist the team with customer questions and issue resolution
• Monitor and analyze aging activity, accounts receivable credits, and cash-to-revenue reports
• Monitor unapplied payments for missing EOBs and communicate required follow-up
• Serve as the internal point person for recoveries and revenue cycle management questions and concerns
• Monitor inbound and outbound customer and insurance payer calls to ensure service-level standards
• Manage employees, including hiring, motivating, coaching, and counseling staff
• Perform other assigned duties
• Comply with all policies and standards

Supervisor, Recovery

Manager

• Oversee care plans/service plans and care management activities for complex care members
• Review and provide expert knowledge for personalized care plans/service plans
• Collaborate with providers, specialists, and community resources to address unmet member needs
• Guide care management team members and triage issues to appropriate healthcare providers
• Monitor member status, outcomes, changes in condition, and revise care plans as needed
• Work with senior management on escalated and complex care cases
• Perform telephonic, digital, home and/or other site outreach to assess member needs
• Review member data to identify health risks and care gaps
• Monitor team policies and procedures for compliance with corporate, state, and NCQA standards
• Partner with healthcare providers to facilitate treatment and determine revised care plans
• Document member information and care management activities for regulatory compliance
• Provide subject matter expertise, training, and education to care management teams and providers
• Partner with leadership to improve cost-effective care and quality delivery
• Perform other duties as assigned and comply with all policies and standards

Lead Care Manager, RN

Vice President

• Lead and manage billing and enrollment processes across multiple regions
• Develop and implement strategic plans for enrollment and billing operations
• Oversee daily operations and ensure compliance with federal, state, and local healthcare regulations
• Manage departmental budgets and analyze financial data in collaboration with finance
• Implement and maintain regulatory compliance policies, conduct audits, and resolve compliance issues
• Maintain high customer satisfaction and strong stakeholder relationships
• Manage and monitor KPIs related to enrollment, billing, and revenue
• Contribute to long-term strategic plans and identify growth opportunities
• Ensure accurate and timely processing of enrollment applications, billing statements, and claims
• Develop and mentor a high-performing team
• Identify and implement process improvements
• Oversee member enrollment, policy administration, claim processing, and revenue cycle management
• Perform other duties as assigned
• Comply with all policies and standards

Vice President – Member Enrollment & Billing

• Develop strategic partnerships between the health plan and contracted provider networks
• Engage with providers to align on network performance opportunities and solutions
• Provide consultative account management and accountability for issue resolution
• Drive performance in contract incentive performance, quality, and cost utilization
• Participate in development of network management strategies
• Assist in strategic implementation of initiatives for performance improvement
• Serve as primary contact and liaison between providers and the health plan
• Identify and deliver solutions to provider concerns and issues
• Receive and respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Educate providers on referrals, claims submission, website usage, EDI solicitation, and related topics
• Perform provider orientations and ongoing provider education
• Write and update orientation materials
• Manage network performance for assigned territory through consultative/account management
• Evaluate provider performance and develop strategic improvement plans
• Drive improvement in Risk/P4Q, HBR, HEDIS/quality, cost, and utilization
• Present HBR analysis and create reports for Joint Operating Committee meetings
• Develop proficiency in VBP tools and educate providers on tool use and data interpretation
• Coach new and less experienced External Representatives
• Perform other duties as assigned
• Comply with all policies and standards

VBC Performance Manager

• Manage behavioral health utilization review clinicians to ensure appropriate member care
• Oversee compliance with applicable guidelines, regulations, contractual and accreditation standards, and industry best practices
• Review and analyze utilization management activities, utilization levels, operations, costs, and forecasted data
• Track goals, objectives, and HBR performance for the behavioral health utilization management team
• Manage and review utilization management and financial reports, identify trends, and recommend improvements to senior leadership
• Identify and present process improvements to the behavioral health senior leadership team
• Develop and implement utilization management policies, procedures, and guidelines
• Educate and provide resources to the utilization management team
• Oversee training and support onboarding, hiring, and training strategies for team members
• Provide career development feedback to Supervisors and lead talent management activities
• Attend company meetings in the people leader's absence
• Manage escalated calls and issues requiring additional research or special handling
• Lead change and manage cross-functional work within tight deadlines
• Perform other duties as assigned and comply with all policies and standards

Senior Manager, Behavioral Health Utilization Management

• Oversee, lead, and drive end-to-end program management
• Develop national duals strategy, including Medicare Advantage and duals-related public policy priorities
• Build trusted relationships with internal leaders and external stakeholders to influence key policy decisions and long-term strategy
• Manage internal and external relationships and obtain state/federal request support and feedback
• Maintain transparent communications and gain alignment from decision makers at all levels
• Develop policy-informed strategy and playbooks across multiple markets
• Advise the DIO team on regulatory matters and their impact on business strategy
• Oversee stakeholder advisory groups
• Partner with LOB leadership on preparation, representation, coordination, and aligned communication
• Select, develop, empower, and deploy direct reports
• Partner with Compliance and Regulatory Affairs on regulatory filings, requests, and submissions
• Lead change management efforts across the Medi-Cal team, functional areas, and California market

Director, Duals Strategy – Policy

Trainer

• Develop and conduct training programs and/or auditing tools for Centene Pharmacy Services employees
• Conduct training needs analyses
• Identify, select, and develop training programs and training aids
• Evaluate training program effectiveness, including cost and benefit analyses
• Research, analyze, and recommend external training programs
• Maintain records of training activities and employee progress
• Assist in auditing staff work and present findings and improvement recommendations to management
• Assist with policy and procedure revisions and work process development
• Perform other assigned duties
• Comply with policies and standards

Trainer I

Advisor

• Work with Centene associates across the company to develop and execute Duals Integration Office strategies supporting business objectives
• Conduct independent research and analysis on policy proposals, including business and strategy impacts
• Provide subject matter expertise on policy areas within the assigned portfolio
• Prioritize multiple health policy deliverables and lead cross-functional projects with little oversight
• Lead and manage functional policy portfolio areas and complete projects amid ambiguity or adversity
• Analyze legislation and regulations impacting Centene plans and products
• Provide policy expertise covering Medicare Advantage and Part D, Marketplace, dual eligibles, Health IT, and Artificial Intelligence
• Develop position papers, talking points, meeting summaries, policy briefs, fact sheets, and presentations for senior executives
• Lead comment letter and RFI development in response to legislative proposals, RFIs, and NPRMs
• Represent Centene Public Policy priorities at meetings with trade associations and report back on developments
• Create internal and external communications materials, regulatory summaries, policy memos, and comment letters
• Perform other duties as assigned and comply with policies and standards

Senior Director, Contracting & Network Development

Operational Risk Analyst

Clinical Investigator – Behavioral Health

Senior Compliance Analyst

Senior Compliance Analyst

Program Manager IV – Clinical Technology Operations

Special Investigation Unit Investigator

Supervisor, Recovery

Lead Care Manager, RN

Vice President – Member Enrollment & Billing

VBC Performance Manager

Senior Manager, Behavioral Health Utilization Management

Director, Duals Strategy – Policy

Trainer I

Strategy and Policy Advisor