Centene Corporation

Growth Marketing

• Plan and direct all aspects of the operations for assigned products and its programs
• Responsible for the short- and long-term profitability and growth of the product programs
• Oversee all aspects of the assigned products and its programs, including operational policies, objectives, and initiatives
• Responsible for the financial performance and growth of the product programs, including profit & loss
• Develop and implement short- and long-range strategic growth and development plans and budgets for the product programs
• Identify opportunities for increased operational efficiencies, develop plans to address needs and ensure successful implementation
• Develop policies and procedures for operational processes in order to ensure optimization and compliance with established standards and local, state and federal regulations
• Represent the organization in its relationships with key stakeholders related to the product programs

Vice President, Duals Performance – Growth

Risk

• Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends/schemes
• Monitor business processes and systems to assure integrity and compliance in billing and claims payment
• Lead teams of analysts to appropriately investigate all possible fraud, waste and abuse referrals
• Develop customized fraud plans to meet contract and federal requirements
• Develop educational materials to identify/validate waste activities as requested by the health plan and on an ad-hoc basis
• Respond to RFP request and implement new policies per contractual obligation
• Attend state/federal meetings as required by specific contracts
• Prepare/present the FWA program to state/federal personnel upon request, specifically during readiness reviews, and immediately following the go live or upon state agency personnel changes
• Review post-payment cases with appropriate parties to obtain refund
• Prepare and distribute monthly and quarterly saving reports

Manager, Payment Integrity – Policy Governance

Compliance

• Oversee all compliance functions for the Mississippi health plan including communication and coordination of policy development
• Oversee the accurate and timely submission of over-contract deliverables for all lines of business and service delivery areas
• Oversee the accurate and timely submission of all CMS Medicare SNP requirements
• Serve as senior leadership and single point of contact in all State compliance meetings and interactions
• Manage direct correspondence and daily interaction with all state regulators
• Serve as senior leadership in all Department of Insurance and HHSC audit processes
• Managing all facets of the audit and communications
• Serve as senior leadership in Enterprise Risk Management process working directly with corporate ERM and Executive Management team to ensure current evaluation and documentation of business risks
• Conduct internal compliance audits, write corrective action plans and work with contract and department managers to ensure timely completion and compliance with federal, state and local regulatory requirements
• Accountable for the management and oversight of compliance for all health plan material subcontractors to include directing the performance of annual oversight
• Performs other duties as assigned.
• Comply with all policies and standards.

Compliance Officer

• Provide strategic leadership and oversight for the health plan compliance program, including compliance governance, regulatory strategy, policy development, and cross-functional implementation.
• Ensure accurate and timely execution and regulatory deliverables across business and operational areas.
• Lead the design, execution, and ongoing effectiveness of the market compliance program in alignment with enterprise standards and regulatory expectations.
• Oversee compliance with CMS Medicare requirements including SNP related obligations, and ensure timely submission of all applicable regulatory filings and deliverables.
• Serve as senior compliance leader and single point of contact for state interactions, compliance meetings and market level escalations.
• Collaborate with Corporate Enterprise Risk Management and market leaders to identify, assess, document, and reduce compliance and business risks.
• Internal compliance auditing and monitoring activities, direct corrective action planning, and hold business owners accountable for timely remediation and sustained compliance.
• Provide oversight of delegated entities, vendors, and material subcontractors, including annual oversight performance monitoring and corrective action follow up.
• Chair or support market compliance committees and provide regular reporting to market and enterprise leadership regarding risks, trends and remediation activities.
• Lead, coach, and develop compliance team members, and establish clear priorities, accountabilities and performance expectations.
• For New Jersey plan only additional responsibilities: Maintain and track contract documentation, Medicaid contract amendments, and various regulatory measures.
• Work with Operational Departments to ensure that policies, procedures, and processes are developed and modified to comply with state regulatory standards.
• Provide guidance to various departments with respect to regulatory and contract language.
• Develop strategic relationships with agencies within the New Jersey Department of Human Services and other state regulatory policymakers with oversight responsibility for Managed Care organizations, Medicare and Medicaid initiatives.
• Identify, evaluate and analyze the impact of state regulatory changes and advise management concerning impact .
• Represent senior management at various state committees, meetings, and industry forums and other engagements relevant to compliance and regulatory strategy.
• Maintain deep knowledge of New Jersey Medicaid and applicable state regulatory requirements.

Manager

• Oversee and monitor the performance of both internal and external cost recovery and cost containment initiatives according to targeted project metrics and forecasted recovery and cost avoidance goals for each Health Plan
• Manage internal and external vendors cost avoidance and cost recovery initiatives
• Partner with health plans to identify and contain cost through collaboration with national vendors for each recovery category
• Develop annual budget and projected target for each national vendor and assist them with achieving projected annual savings
• Evaluate and streamline existing processes and implement new processes to reduce costs
• Present trends and cost containment opportunities, recommend action plans, and assist with the implementation of those plans
• Assist health plans in understanding the rules, regulations and processes around cost recovery
• Monitor other departments’ performance and processes and evaluate for cost recovery
• Compile and Present reporting packages for Senior Management on current cost avoidance and cost recovery initiatives

Senior Manager, Payment Integrity

• Provide strategic leadership and oversight for the health plan compliance program, including compliance governance, regulatory strategy, policy development, and cross-functional implementation.
• Ensure accurate and timely execution and regulatory deliverables across business and operational areas.
• Lead the design, execution, and ongoing effectiveness of the market compliance program in alignment with enterprise standards and regulatory expectations.
• Oversee compliance with CMS Medicare requirements including SNP related obligations, and ensure timely submission of all applicable regulatory filings and deliverables.
• Serve as senior compliance leader and single point of contact for state interactions, compliance meetings and market level escalations.
• Serve as senior leadership in all Department of Insurance, Medicaid agency, and other regulatory audit activities applicable to New Hampshire market.
• Collaborate with Corporate Enterprise Risk Management and market leaders to identify, assess, document, and reduce compliance and business risks.
• Oversee internal compliance auditing and monitoring activities, direct corrective action planning, and hold business owners accountable for timely remediation and sustained compliance.
• Provide oversight of delegated entities, vendors, and material subcontractors, including annual oversight performance monitoring and corrective action follow up.
• Chair or support market compliance committees and provide regular reporting to market and enterprise leadership regarding risks, trends and remediation activities.
• Lead, coach, and develop compliance team members, and establish clear priorities, accountabilities and performance expectations.

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
• 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
• Assists the Chief Medical Director in the functioning of the physician committees
• Conduct regular rounds to assess and coordinate care for high-risk patients
• 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
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers
• 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
• May be required to work weekends and holidays in support of business operations, as needed

Medical Director, Appeals

Data Analyst

• Analyze integrated and extensive datasets to extract value, which directly impacts and influences business decisions
• Work collaboratively with key business stakeholders to identify areas of value, develop solutions, and deliver insights to reduce overall cost of care for members and improve their clinical outcomes
• Focus on enterprise provider analytics to measure and report the actual impact of contract and network changes against projected outcomes
• Deliver standardized, structured reporting to track implementation accuracy and validate savings
• Interpret and analyze data from multiple sources including claims, provider, member, and encounters data
• Identify and assess the business impact of trends
• Develop, maintain, and troubleshoot complex scripts and reports developed using SQL, Microsoft Excel, or other analytics tools
• Contribute to the planning and execution of large-scale projects with limited direction from leadership
• Assist in the design, testing, and implementation of process enhancements and identify opportunities for automation
• Identify and perform root-cause analysis of data irregularities and present findings and proposed solutions to leadership and/or customers
• Manage multiple, variable tasks and data review processes with limited supervision within targeted timelines and thrive in a demanding, quickly changing environment
• Demonstrate a sense of ownership over projects and ask probing questions to understand the business value of tasks
• Apply expertise in quantitative analysis, data mining, and the presentation of data to see beyond the numbers and understand how customers interact with analytic products
• Partner cross-functionally at all levels of the organization and effectively, both verbally and visually, communicate findings and insights to non-technical business partners
• Independently engage with customers and business partners to gather requirements and validate results
• Communicate and present data-driven insights and recommendations to both internal and external stakeholders, soliciting and incorporating feedback when required
• Provide technical guidance to junior analysts

Data Analyst III – Healthcare Analytics, Provider Analytics

Program Manager

• Provide operational leadership for Centene's Corporate Risk Adjustment program operations and its subsidiaries
• Oversee compliance with Risk Adjustment data integrity and validation audit process
• Lead enterprise-wide Risk Adjustment operations for coding and external audits, ensuring consistent execution while addressing market, product, and regulatory variation
• Lead and develop high performing, multi-disciplinary teams through complex change, reinforcing accountability, engagement, and results
• Drive enterprise change management through standardized processes, tools, and controls that improve scalability, quality, and compliance
• Oversee encounter data submissions and reconciliation to ensure data completeness, accuracy, and regulatory alignment
• Effectively communicate risk, organizational impact and progress towards achieving goals
• Establish strong governance and oversight for Risk Adjustment compliance, including RADV and other regulatory and internal audits
• Work with local market teams as necessary to support Enterprise Risk Adjustment programs and education
• Ensure disciplined oversight of vendor performance, holding partners accountable to quality, timeliness, and contractual expectations
• Performs other duties as assigned.
• Complies with all policies and standards.

Vice President, Risk Adjustment Program Operations, Data Integrity

• Assist the Chief Medical Officer 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 Officer 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 Officer 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
• As needed, 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

• Develops and implements strategies to ensure successful maintenance and implementation of compliance and risk programs
• Champions cross-functional collaboration by working closely with Risk & Compliance teams, business units, legal, IT, and operational leaders
• Leads the documentation of processes and controls
• Oversees the review and periodic update of compliance process documentation
• Serves as the principal liaison between business/process stakeholders, GRC Administration team, and technology teams
• Architects and implements governance structures for the GRC application
• Designs and maintains robust standards and criteria for business cases submitted to the governance committee
• Develops a framework to evaluate and interpret data outputs and reporting generated from activities recorded in the GRC tool
• Champions other strategic initiatives as assigned supporting Risk & Compliance Programs

Director, Risk & Compliance Processes – Initiatives

• Drive the execution of analytics strategy through the discovery, development, and implementation of leading-edge analytics that answer important business questions
• Align talent and resources to support enterprise and health plan needs by leveraging data to achieve strategic objectives and improve business performance
• Lead enterprise analytics to forecast, measure, and validate the financial impact of provider contract and network strategy changes
• Ensure projected savings and outcomes are realized by overseeing post‑implementation tracking, savings validation, and executive‑level reporting
• Lead the planning and execution of enterprise-wide analytics projects and strategic initiatives, translating business goals into actionable solutions
• Manage development efforts as a liaison with business and technical partners, including managing stakeholder expectations, requirements gathering, testing, deployment and user adoption
• Prioritize team work, manage customer expectations and relationships, and maintain alignment of deliverables with business needs and strategic objectives
• Support customer engagement and satisfaction by maintaining effective communication and transparency of work and deliverables with core stakeholders
• Partner cross-functionally at all levels of the organization and communicate findings and insights to non-technical business partners
• Independently engage with business leaders to understand market-specific levers and constraints
• Leverage enterprise reporting tools to rapidly deliver data-driven insights and recommendations
• Facilitate cross-team project collaboration between state-based health plans and business units, including IT, Finance, Network Development, and Payment Integrity
• Mentor, manage, and ensure the continuous development of team.

Manager, Healthcare Analytics, Enterprise Provider Analytics

Operations

• Oversee business operations, procurement opportunities, new product implementations and complex initiatives for business development utilizing cross-functional business units and corporate teams
• Partner with multiple stakeholders and leadership to establish strategic visions, operational objectives, and policies and procedures ensuring compliance with state contracts, related laws, regulations and executive orders
• Monitor and report achievement of committed action plans to senior management
• Direct the development and implementation of operational work processes and systems with direct oversight for multiple departments within the business unit
• Accountable for budget, revenue targets, and Profit & Loss
• Lead and oversee new business implementation and procurement activities for all products and complex projects, including RFP responses
• Evaluate program opportunities and recommendations for effectiveness and ROI
• Perform duties as senior liaison between the business unit, corporate, and external stakeholders
• Oversee preliminary discovery, due diligence for potential liabilities, internal control weaknesses, and financial integrity

Vice President, Claims Configuration Operations – Health Plan

• accountable for the strategic leadership and oversight of all provider network operations
• direct the accurate, timely, and compliant management of provider data
• oversee and optimize the provider credentialing process
• champion initiatives to advance market service excellence by implementing process improvements
• lead and coordinate across the enterprise, facilitating cross-functional collaboration
• ensure unwavering compliance with all healthcare regulations, Centene policies
• promote and drive the adoption of industry best practices
• establish, monitor, and report on key performance indicators (KPIs)

Head of Provider Operations

• Analyze integrated and extensive datasets to extract value, which directly impacts and influences business decisions.
• Work collaboratively with key business stakeholders to identify areas of value, develop solutions, and deliver insights to reduce overall cost of care for members and improve their clinical outcomes.
• Analyze and run complex reports, understand financial drivers and cost trends, and apply insights to optimize medical spend while maintaining quality of care.
• Interpret and analyze data from multiple sources including healthcare provider, member/patient, and third-party data.
• Lead the planning and execution of large-scale projects and new reporting tools, translating business goals into actionable solutions.
• Identify and resolve data, process, and technical issues and communicate root-cause with stakeholders as appropriate.
• Partner cross-functionally at all levels of the organization and effectively communicate findings and insights to non-technical business partners.
• Independently engage with business leaders to understand market-specific levers and constraints.
• Leverage enterprise reporting tools to rapidly deliver data-driven insights and recommendations.
• Research key business problems and proactively identify opportunities for cost and utilization improvements through quantitative analysis.
• Communicate and present data-driven insights and recommendations to both internal and external stakeholders, soliciting and incorporating feedback when required.
• Mentor junior analysts on analytic best practices and business need fulfilment.
• Delegate tasks to junior analysts, providing guidance and validation where required.

Vice President, Duals Performance – Growth

Manager, Payment Integrity – Policy Governance

Compliance Officer

Compliance Officer

Senior Manager, Payment Integrity

Compliance Officer

Medical Director, Appeals

Data Analyst III – Healthcare Analytics, Provider Analytics

Vice President, Risk Adjustment Program Operations, Data Integrity

Medical Director

Director, Risk & Compliance Processes – Initiatives

Manager, Healthcare Analytics, Enterprise Provider Analytics

Vice President, Claims Configuration Operations – Health Plan

Head of Provider Operations

Data Analyst IV, Healthcare Analytics, Medical Economics