Centene Corporation

General

• Conduct reviews of delegated entities for compliance with quality, service performance, utilization, credentialing, and medical record audit requirements
• Perform quality on-site reviews of delegated entities, physician offices, and clinics
• Resolve quality issues and generate written summaries of findings
• Follow up as directed by the Medical Director and/or Credentialing and Quality Improvement Committee
• Document, investigate, and resolve formal and informal complaints, risk management, and sentinel events related to quality-of-care issues
• Audit medical records, review administrative claims, and analyze data and interventions for quality improvement studies and activities
• Serve as primary liaison between community resources/agencies and the company for clinical initiatives and technical guidance
• Schedule and chair meetings with delegated entities according to contract requirements
• Gather data and compile utilization and quality improvement reports
• Develop and implement Corrective Action Plans
• Recommend changes and enhancements to Quality Improvement policies and procedures
• Identify best practices, research new processes, and recommend program enhancements
• Coordinate QIC activities and monthly meetings
• Oversee enforcement of contract terms regarding data submission for delegated entities
• Participate in development of reporting and data outcome reports
• Perform other duties as assigned

Quality Improvement Coordinator II

• Conduct review of delegated entities for compliance with quality, service performance and utilization, credentialing reviews and medical record audits
• Perform community activities related to clinical initiatives such as health fairs
• Communicate with agencies and providers
• Perform quality on-site reviews of delegated entities and physician offices/clinics
• Resolve quality issues and generate written summaries of findings
• Follow up as directed by the Medical Director and/or Credentialing and Quality Improvement Committee (QIC)
• Document, investigate and resolve formal and informal complaints, risk management and sentinel events related to quality of care issues
• Audit medical records, review administrative claims and analyze data and interventions for quality improvement studies and activities
• Function as the primary liaison between community resources/agencies and the company related to clinical initiatives and technical guidance
• Schedule and chair meetings with delegated entities in accordance with their contract
• Gather data and compile utilization and quality improvement reports
• Develop and implement Corrective Action Plans
• Recommend changes and enhancements to Quality Improvement policies and procedures
• Identify best practices, research new processes and recommend program enhancements
• Coordinate QIC activities and monthly meetings
• Oversee enforcement of contract terms regarding data submission for delegated entities
• Participate in development of reporting and data outcome reports
• Perform other duties as assigned

Manager

• Develop, implement and manage strategic fraud, waste and abuse activities
• Maintain state and federal requirements and monitor trends and schemes
• Monitor business processes and systems for integrity and compliance in billing and claims payment
• Lead teams of analysts investigating fraud, waste and abuse referrals
• Develop customized fraud plans for contract and federal requirements
• Develop educational materials to identify and validate waste activities
• Respond to RFP requests and implement new policies per contractual obligations
• Attend state and federal meetings as required by contracts
• Prepare and present the FWA program to state and federal personnel
• Review post-payment cases to obtain refunds
• Prepare and distribute monthly and quarterly savings reports
• Perform other duties as assigned
• Comply with all policies and standards

Manager, Payment Integrity Insights – Innovation

Data Analyst

• Analyze integrated and extensive datasets to extract value and influence business decisions
• Collaborate with business stakeholders to identify value, develop solutions, and deliver insights that reduce cost of care and improve clinical outcomes
• Interpret and analyze claims, provider, member, and encounters data
• Identify and assess the business impact of trends
• Develop, maintain, and troubleshoot complex scripts and reports using SQL, Microsoft Excel, or other analytics tools
• Lead enterprise-wide projects and strategic initiatives, translating business goals into actionable solutions
• Identify and resolve data, process, and technical issues and communicate root causes with stakeholders
• Partner cross-functionally and communicate findings to non-technical business partners
• Engage with business leaders to understand market-specific levers and constraints
• Leverage enterprise reporting tools to deliver data-driven insights and recommendations
• Research business problems and identify opportunities for cost and utilization improvements through quantitative analysis
• Present insights and recommendations to internal and external stakeholders, incorporating feedback
• Facilitate collaboration between state-based health plans and business units including IT, Finance, Network Development, and Payment Integrity
• Serve as a business leader and subject matter expert for data domains
• Consolidate and review analyses and recommendations from business partners
• Mentor analysts on analytic best practices
• Delegate tasks and provide guidance and validation

Lead Data Analyst – Healthcare Analytics

• Provide administrative support for the Foster Care/DCYF team
• Assist Care Managers and Care Navigators with emailing and updating monitoring care plans
• Maintain assigned monitoring care plans
• Complete member outreach to support comprehensive assessments
• Connect members to community resources supporting their care management journey
• Provide members with known community resources and health education as appropriate
• Support members in connecting to community and care resources
• Coordinate community outreach resources and promote awareness of care/services
• Respond to member inquiries about community and care resources
• Support member correspondence and educational materials
• Escalate community resource requests and inquiries to management
• Document and maintain community resources in accordance with health plan requirements
• Support nurses and social workers with outreach, community education, evidence-based guidance, and member support
• Conduct non-clinical general health assessments and refer members to appropriate services
• Conduct non-medical assessments and resolve concerns on members’ behalf
• Conduct telephonic and/or in-person outreach to locate hard-to-reach individuals and families
• Make visits to individual homes and/or community organizations as needed
• Perform other duties as assigned

Community Resource Coordinator III

Risk

• Engage and educate providers on accurate capture and reporting of chronic conditions for revenue management
• Ensure programs follow state and federal guidelines
• Engage, train, and provide monthly reporting for 60–100 providers
• Use data to develop strategies and best practices that help providers earn incentives and increase company revenue
• Ensure medical records are received and work with vendors to overcome barriers
• Ensure providers comply with mandated audits and medical record requests
• Conduct outreach through phone, email, and Zoom meetings
• Serve as point of contact for provider questions, reports, and issues throughout projects
• Use Excel and internal tools to develop engagement, issue, and progress reporting
• Review and analyze project data to identify barriers and develop provider-success strategies
• Use vendor portals to identify barriers to receiving medical records for risk adjustment
• Research provider information using internal systems and the internet
• Outreach to provider offices and share best practices to obtain medical records for coding and abstraction

Risk Adjustment Specialist – Non-Clinical

• Lead a team responsible for end-to-end Medicare, Duals, and Marketplace audit activities, including planning, execution, reporting, and corrective action monitoring
• Manage monthly executive reporting and communicate audit results and trends to stakeholders
• Oversee resource allocation and team development
• Drive process improvements that enhance quality, compliance, and operational effectiveness
• Oversee operational audits across claims, provider setup and maintenance, member eligibility, contracting, encounters, provider/member services, and new business implementation
• Oversee monthly claims audit management reporting
• Manage the full life cycle of claims audit reporting and upstream operational audits from requirements gathering through audit closure
• Manage audit work plans, schedules, resources, and budgets
• Facilitate audit execution and reporting through closure of audit periods and operational audits
• Communicate audit results to leadership and corporate and health plan stakeholders
• Evaluate operational processes and controls to identify non-compliance and improvement opportunities
• Maintain audit tools to ensure business requirements are measured during audits
• Coordinate cross-functional corrective action plan meetings to support claims quality improvements

Manager, Provider Reimbursement Audit

Nurse

• Review challenging and complex prior authorization requests to determine medical necessity and appropriate level of care
• Assess authorization requests and provide recommendations to the appropriate medical team
• Perform medical necessity and clinical reviews in accordance with regulatory guidelines and criteria
• Collaborate with healthcare providers and authorization teams to ensure timely service reviews and authorized care
• Escalate requests to Medical Directors when appropriate
• Manage authorization requests related to member transfers and discharge plans
• Provide feedback to improve the authorization review process
• Assess medical necessity with healthcare providers, utilization management, and care management teams
• Partner with interdepartmental utilization management teams on projects
• Review member clinical information in health management systems for regulatory compliance
• Educate providers and interdepartmental teams on utilization processes
• Develop in-depth knowledge of prior authorization and train other team members
• Perform other assigned duties and comply with policies and standards

Senior Clinical Review Nurse – Prior Authorization

• Facilitate medical necessity grievances, appeals, and denials, including disposition of denial notification letters
• Review clinical information to determine whether medical necessity criteria are met
• Review clinical data to determine claim payment based on company policies and NCQA guidelines
• Overturn denied claims, uphold denials, and submit cases to the Medical Director for review
• Identify potential quality-of-care concerns through member grievance and potential quality issue reviews
• Prepare case reviews for the Medical Director when criteria are not met
• Identify system improvements and individual care issues affecting appropriate care or service expectations
• Provide input into corrective action plans for clinical and service events
• Generate appeal resolution communications to members and providers
• Create system authorization events for overturned denial decisions
• Request additional provider information to facilitate timely appeals resolution
• Gather and prepare case information for Administrative Law Hearings
• Maintain the appeals process within NCQA timeframes and the appeals turnaround database
• Assist the Medical Director with revising, updating, or creating policies to satisfy NCQA and contractual requirements
• Act as liaison between providers and the business to resolve issues
• Perform other duties as assigned
• Comply with all policies and standards

Grievance and Appeals Nurse – State

• Manage the resources and results of clinical reviews resulting from providers or claims identified for potential fraud, waste and/or abuse
• Manage review and audit processes for inappropriate billing practices
• Develop medical strategies to correct billing issues
• Review audit reports for accuracy and completeness
• Present findings to Upper Management
• Collaborate with providers and conduct continuous educational training on appropriate billing patterns
• Support legal actions taken by the corporation, state and federal governments
• Oversee implementation of improvement opportunities for effective and efficient audit processes
• Collaborate with the medical management department to help define medical policy based on coding research and medical-record review
• Oversee and review cost savings analysis
• Meet with Medical Directors to validate medical decisions and track cost savings based on clinical denials
• Lead and develop a team of clinical investigators
• Review and evaluate complex Fraud, Waste & Abuse cases
• Apply clinical expertise to identify trends, risks, and potential concerns
• Partner with providers and internal stakeholders on complex cases
• Support healthcare integrity and appropriate utilization of services
• Perform other duties as assigned
• Comply with all policies and standards

Manager, Clinical Review

Care Coordinator

• Support care management activities and assigned member teams to ensure services are delivered and continuity of care/member satisfaction is achieved
• Conduct member outreach by telephone and home visits
• Document care/service plans and related activities
• Engage members and discuss care plans, next steps, resources, questions, concerns, and ongoing education
• Coordinate care activities with healthcare and community providers, partners, members, and caregivers
• Respond to member and provider inquiries, requests, and concerns
• Communicate with care managers, practitioners, and others to facilitate member services
• Support service assessments and screenings and document member care needs
• Maintain member records in accordance with state and regulatory requirements
• Identify needs and make referrals to Care Managers, community-based organizations, and Disease Managers
• Provide education on available benefits and resources
• Perform other duties as assigned and comply with policies and standards

Care Coordinator II

Program Manager

• Lead large-scale, cross-functional projects for implementation or process improvement
• Work with organizational leaders on restructuring and realignment of team members
• Oversee program planning, management, and execution, including scope, schedule, and budget
• Create comprehensive timelines and ensure appropriate deliverables follow project management standards
• Coordinate project managers and business analysts managing individual workgroups
• Create executive-level dashboards and project status updates
• Work with teams to create reports for ongoing post-implementation analytics
• Create and deliver best-practice and training information
• Work with the training team to create and review training materials
• Prepare and deliver documents for Program Steering Committees and the Executive team
• Assess program risks and escalate issues to leadership
• Manage risk, budget/forecast, dependencies, and related areas
• Prepare strategic analyses of business and operational opportunities
• Serve as the first escalation point for project issues and risks
• Resolve issues with project teams and create risk mitigation plans
• Communicate business and technology issues and solutions

Program Manager IV

• Lead activities to achieve membership and enrollment goals through marketing projects, new market initiatives, health fairs, community activities, training, member retention, sales visibility, outreach and networking.
• Research and assess market and business opportunities.
• Plan, develop, coordinate, collaborate on and conduct meetings, presentations, training, orientations, focus groups, field marketing events and projects.
• Develop and maintain business relationships and information to increase membership and enrollment targets.
• Represent the department at vendor, departmental, cross-functional, community and provider meetings.
• Develop sales, broker product training, member retention, new member training and outreach presentations.
• Act as department liaison for market materials, collateral rollouts, inventory and reports.
• Serve as point person on key projects.
• Work with management on workflow policy and procedure documentation, strategy, planning, product, collateral and sales strategies.
• Prospect and initiate field marketing, grassroots lead generation, provider co-op and community venue opportunities.
• Coordinate with the sales team for successful market execution.
• Develop plans to increase crossover enrollment and assist in outreach activities.
• Perform other duties as assigned and comply with all policies and standards.

Community Relations Specialist

• Lead activities to achieve membership and enrollment goals through marketing projects, new market initiatives, health fairs, community activities, training, member retention, sales visibility, outreach and networking
• Research and assess market and business opportunities
• Plan, develop, coordinate, collaborate on and conduct meetings, presentations, activities, training, product orientations, focus groups, field marketing events and projects
• Develop and maintain business relationships and information to increase membership and enrollment targets
• Represent the department at internal and external vendor, departmental, cross-functional, community and provider meetings
• Develop sales, broker product training, member retention, new member training and outreach presentations
• Serve as department liaison for market materials, collateral rollouts, inventory and reports
• Act as point person on key projects
• Work with management on department workflow policies, procedures, strategy, planning, products, collateral and sales strategies
• Prospect and initiate field marketing, grassroots lead generation, provider co-op and community venue opportunities
• Coordinate with the sales team for successful market execution
• Develop plans to increase crossover enrollment and assist in outreach activities
• Perform other duties as assigned and comply with all policies and standards

• Develop, assess, and facilitate complex care management activities for primarily mental and behavioral health needs
• Create personalized care plans and provide education for members and families regarding mental health and substance use disorder
• Evaluate member needs by phone or in-home visits and recommend or facilitate care and service plans
• Conduct telephonic, digital, home, and other site-visit outreach
• Develop ongoing care plans for members with high acuity
• Identify providers, specialists, and community resources needed for care
• Coordinate among members, families, caregivers, community resources, and care provider teams
• Monitor care plans, treatment side effects, complications, clinical symptoms, and member outcomes
• Facilitate care coordination and timely access to needed care and services
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Educate members and families on procedures, provider instructions, treatment options, referrals, and healthcare benefits
• Provide leadership feedback to improve cost-effective care and quality delivery
• Perform other assigned duties and comply with policies and standards