Centene Corporation

General

• Analyze and resolve verbal and written claims and authorization appeals from providers
• Pursue resolution of formal grievances from members
• Gather, analyze and report member and provider complaints, grievances and appeals
• Prepare response letters for complaints, grievances and appeals
• Maintain files on individual appeals and grievances
• May coordinate the Grievance and Appeals Committee
• Support pay-for-performance programs through data entry, tracking, organizing and researching information
• Assist with HEDIS production functions, including data entry, provider-office calls and claims research
• Manage large volumes of documents, including copying, faxing and scanning incoming mail
• Perform other duties as assigned
• Comply with all policies and standards

Grievance & Appeals Coordinator I

Supervisor

• Provide leadership and direction for clinical, quality, risk-adjustment, value-based contracts, and provider outreach functions
• Supervise QPA field staff and administrative personnel
• Increase member quality of care, reduce costs, and identify risk adjustment opportunities
• Oversee programs supporting company initiatives in clinical quality, risk-adjustment, and financial management
• Provide data analysis on program progress and outcomes
• Provide supervision, coaching, training, and development of field staff
• Oversee and manage quality and risk-adjustment initiatives/programs
• Provide and analyze reports to identify trends, opportunities, and plans regarding initiative progress and outcomes
• Collaborate with other managers on team strategy and direction
• Collaborate with cross-functional teams on joint initiatives
• Perform other duties as assigned
• Comply with all policies and standards

Supervisor, Quality Practice Advisor

Business Analyst

• Perform analysis and interpretation to link business needs and objectives for the assigned function
• Support business initiatives through data analysis, identification of implementation barriers, and user acceptance testing of various systems
• 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
• Identify ways to enhance performance management and operational reports related to new business implementation processes
• Coordinate with business units and departments in the development and delivery of 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 to ensure operational performance
• Perform other duties as assigned
• Comply with all policies and standards

Business Analyst III

Medical Director

• Accountable for the performance of a portfolio of Medical Management initiatives
• Implement the Health Equity Cultural Competency Program
• Plan, manage, implement, and support initiatives that create value and savings across clinical operations
• Lead implementation of new medical management programs with specialty vendors
• Evaluate specialty companies/vendors and define business terms during contracting
• Oversee and directly manage a team responsible for project management, performance improvement, and clinical analytics
• Collaborate with internal and external stakeholders to identify, develop, and implement innovative programs and initiatives
• Promote cultural competence throughout the health plan
• Develop provider trainings to improve cultural awareness and competency
• Partner with community, regional, and statewide organizations to improve culturally competent programs and services
• Assess provider-network cultural diversity, identify resources and gaps, and develop credentialing and network-development recommendations
• Monitor and evaluate provider practices through KPIs within health equity dashboards
• Implement population-specific training, media awareness, and community support activities
• Identify population trends, health disparities, care gaps, and recommend interventions
• Create outreach, community activities, and innovative programming to engage populations in services
• Create and implement a comprehensive, outcomes-based Cultural Competency Plan aligned with CLAS standards and national and regional priorities

Senior Director – Healthcare Transformation, Health Equity

Clinician

• Perform clinical reviews to resolve and process appeals
• Review medical records and clinical data to determine medical necessity according to policies, guidelines, and NCQA standards
• Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing appeal bases
• Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards
• Communicate with members, providers, facilities, and other departments regarding appeal requests
• Generate appeals resolution communications and reports for members and providers
• Work with leadership to improve consistency, efficiency, and appropriateness of appeal responses
• Partner with interdepartmental teams to improve clinical appeals processes and prevent recurrences
• Perform other assigned duties and comply with company policies and standards

Clinical Review Clinician – Appeals

Auditor

• Develop and implement effective business solutions through research, audit, and data and/or business-process analysis
• Audit and validate routine pre- and post-payment claims for correct adjudication and compliance
• Audit provider data loaded into claims processing systems
• Document and report audit results
• Research claims and enrollment discrepancies related to provider data
• Manage other provider data management-related projects
• Review and support the claims process for medical review and cost-saving initiatives
• Maintain department statistics for quality improvement indicators, regulatory agencies, and certification bodies
• Perform routine and moderately complex audits on medical review claims to identify exceptions
• Research reviewed-claim issues to determine origins and appropriate resolutions
• Summarize findings and recommendations in reports and distribute them to management
• Communicate audit and review results with the claims department to improve processing and resolutions
• Provide qualified data for training programs, policies, and procedures
• Maintain current knowledge of Health Net products, policies, procedures, coding, industry regulations, and certification standards

Senior Quality Auditor

Advisor

• Establish and foster healthy working relationships between large physician practices, IPAs and Centene
• Educate providers and support provider practice sites regarding NCQA HEDIS measures and risk adjustment
• Provide education on HEDIS measures, medical record documentation, and appropriate coding
• Assist in resolving deficiencies affecting plan compliance with State and Federal HEDIS and documentation standards
• Serve as a resource for health plan peers on HEDIS measures, documentation, and coding
• Support development and implementation of quality improvement interventions and provider-related audits
• Deliver advice and education to provider practices and IPAs on HEDIS measures, documentation guidelines, and HEDIS ICD-9/10 CPT coding
• Collect, summarize, trend, and deliver provider quality and risk adjustment performance data
• Identify and strategize or coach on provider improvement and gap-closure opportunities
• Collaborate with Provider Relations and other provider-facing teams to improve performance in Quality, Risk Adjustment, and Operations
• Identify practice needs where Centene can provide support
• Develop, enhance, and maintain provider clinical relationships across product lines
• Maintain Quality KPIs and HEDIS abstraction accuracy rates according to corporate standards
• Travel to provider offices up to 75% of the time
• Comply with policies and standards and perform other assigned duties

Quality Practice Advisor

Call Center Representative

• Manage the customer service function, including technology needs and implementation
• Lead daily operations of a Specialty Pharmacy Patient Services call center
• Oversee approximately 3–8 direct reports and provide indirect leadership and support to front-line team members
• Manage workflow and ensure compliance with established benchmarks and standards
• Monitor service levels, call volume, staffing, productivity, quality, and customer experience metrics
• Forecast call volume and determine appropriate staffing levels
• Develop and maintain department performance and productivity reports
• Identify operational risks and make timely decisions
• Coach Supervisors on performance management and employee development
• Coordinate complex patient, provider, and internal escalations
• Partner with cross-functional operational departments and teams
• Implement customer service initiatives to improve operational efficiency and quality performance
• Review, investigate, and resolve complex member and provider services inquiries
• Develop and implement policies and procedures meeting contractual, legal, regulatory, and quality requirements
• Identify process and infrastructure needs for existing and new business initiatives
• Assist with short- and long-term objectives and implement actions to achieve goals
• Assist with implementation of major operational projects
• Maintain operational reporting and communicate business updates

Manager, Patient Services – Call Center, Pharmacy

Procurement

• Manage strategic vendor partnerships and enterprise initiatives, including vendor evaluation, contracting, implementation, governance, and performance oversight
• Evaluate and support strategic enterprise vendor opportunities
• Develop business cases and coordinate RFI/RFP activities
• Lead vendor selection activities, contract development, negotiations, and implementations
• Lead stakeholder and oversight meetings with vendors, business leaders, and cross-functional stakeholders
• Provide executive-level reporting and recommendations on vendor performance, business opportunities, and strategic initiatives
• Facilitate collaboration between vendors and Clinical, Operations, Finance, Compliance, Procurement, Legal, and Technology teams
• Monitor and report vendor performance metrics to business unit management
• Communicate vendor expectations and performance against established metrics
• Develop, implement, and follow up on annual vendor goals and targets
• Ensure vendor performance improvement plans and corrective action plans are initiated and completed
• Verify sustained vendor performance improvements and outcomes through audits
• Conduct oversight meetings with vendors, internal partners, and other stakeholders
• Oversee health plan participation in annual delegation audits
• Follow through on audit deficiencies to ensure corrective actions are implemented

Director, Vendor Management

Analyst

• Analyze contact center workload to build resourcing and optimize scheduling plans
• Develop staffing schedules to maximize resource efficiency and meet customer demand
• Analyze contact center volumes, trends, productivities, unexpected absences, schedule deviations, and operational disruptions
• Evaluate forecasted workload results to build resourcing and scheduling plans
• Analyze centralized versus decentralized queue strategies and their impact on service level, average speed of answer, staff adherence, and staffing plans
• Evaluate key performance metrics to identify improvement areas and make data-driven recommendations
• Assess contact center staff productivity and prepare feedback for supervisory staff
• Maintain accurate records of schedules, time-off requests, and staffing-related information
• Ensure scheduled and ad-hoc reports on contact center effectiveness and efficiency
• Assist in developing workforce management policies and procedures
• Comply with policies and standards and perform other duties as assigned

Workforce Scheduling Analyst II

Proposal Manager

• Develop written responses to complex, high-scoring Medicaid Request for Proposal (RFP) sections supporting the company's growth and expansion goals
• Project manage and respond to assigned high-scoring RFP questions in support of new business and renewal procurement
• Partner with internal functional area Subject Matter Experts (SMEs) to translate policies, examples, and reports into compelling narrative
• Ensure responses comply with RFP requirements and drafting guides and align with win themes and key differentiators
• Develop topic papers in assigned areas before RFP release
• Serve as the department’s SME for assigned functional areas
• Provide backup support for department reporting, competitive intelligence, and project management activities
• Mentor departmental staff and assist in RFP responses and reviews
• Perform other duties as assigned
• Comply with all policies and standards

Lead Proposal Writer

Investigator

• 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
• 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 efforts, 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 member, provider, and witness interviews
• Perform other duties as assigned
• Comply with all policies and standards

Special Investigation Unit Investigator

Chief Marketing Officer

• Drive market-leading business acquisition growth and retention through national operating scale and consumer-insight driven marketing activations for ICHRA plans
• Build five-year, growth-oriented, integrated multichannel marketing strategies
• Build and execute annual marketing plans connected to line-of-business and sales teams
• Lead marketing team and agency partners in executing creative, content, omnichannel media, web, SEO, and direct-mail plans
• Partner with Marketing Operations and Analytics to advance DRTV, precision marketing, and data analytics capabilities
• Optimize BME investment allocation and support ROI-driven investment decisions and scenario planning
• Lead day-to-day partnerships with creative, media, and SEO agency partners
• Support agency scopes of work and budgets
• Create a digital-first, consumer- and market-focused marketing team and culture
• Develop a culture of learning, performance, inclusion, health, and community giving
• Equip people managers with training and coaching for talent recruitment and management
• Accelerate development of diverse talent through sponsored programs and active mentorship
• Empower teams to act with speed, agility, and accountability
• Influence partners to develop new products incorporating customer insights and needs
• Collaborate with Product, Sales, Operations, Finance, HR, Compliance, and other business partners

Senior Director, Marketing

• Supervise drafting and processing of correspondence in accordance with NCQA requirements
• Supervise day-to-day activities and guide the correspondence team to ensure timely review and processing
• Monitor and track correspondence issues and research documentation, processing, and resolution
• Provide expert knowledge and guidance for issue resolution and processing
• Ensure team compliance with contract requirements, policies, procedures, and performance standards
• Identify opportunities for process and quality improvements within denial processing and review
• Evaluate team performance and provide feedback on performance, goals, and career milestones
• Coach and guide the team to ensure timely documentation and improve correspondence processing and quality
• Assist with onboarding, hiring, and training team members
• Lead and champion change within scope of responsibility
• Perform other duties as assigned
• Comply with all policies and standards

Supervisor, Correspondence

Operations

• Serve as a strategic business partner overseeing vendor relationship management and financial performance for assigned business units or delegated entities
• Lead annual budget (AOP) development, forecasting, invoice and spend management, vendor performance, and RFP oversight
• Prepare and manage annual operating plans, monthly budgets, and reforecast cycles
• Integrate actual results into Cognos/Hyperion budgeting models while ensuring accounting and policy consistency
• Analyze monthly variances, identify key drivers, and provide actionable leadership insights
• Monitor SG&A budgets for cost efficiency and adherence to financial targets
• Manage invoice validation, accruals, and vendor payment tracking
• Support executive presentations with financial summaries, trends, and recommendations
• Perform complex financial analyses to evaluate business performance and identify improvement opportunities
• Manage assigned vendor relationships, contractual compliance, performance monitoring, and financial accountability
• Develop and maintain vendor scorecards, SLA dashboards, and corrective action plans
• Partner with Procurement on RFP development, bid evaluation, and vendor selection
• Conduct vendor review meetings assessing operational performance, cost effectiveness, and strategic alignment
• Collaborate with Medical Management, Provider Services, Finance, and Operations
• Implement process improvements to optimize vendor performance and reduce costs
• Deliver reporting on vendor and financial metrics to internal and external stakeholders
• Prepare reports and responses for executive management and board-level presentations
• Maintain adherence to contracts, company policies, and applicable regulations
• Lead or contribute to special projects, RFPs, and cross-functional strategic initiatives
• Perform other assigned duties and comply with policies and standards