Centene Corporation

Medical Director

• Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit
• Oversee the denials and appeals department
• May manage other medical directors
• Provide medical leadership for all utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement activities
• Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services
• Support the effective implementation of performance improvement initiatives for capitated providers
• Assist VPMA in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Utilize the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Participate in provider network development and new market expansion as appropriate

Senior Medical Director – YouthCare

Business Analyst

• Perform and lead various analysis and interpretation to link business needs and objectives for assigned function and implement process improvements
• Lead the support of business initiatives through data analysis, identification of implementation barriers and user acceptance testing of various systems
• Lead the identification and analysis of user requirements, procedures, and problems to improve existing processes
• Resolve issues and identify opportunities for process redesign and improvement
• Perform detailed analysis on multiple projects, recommend potential business solutions and ensure successful implementations, including improvements and revisions to business processes and requirements
• Evaluate risks and concerns and communicate to management
• Coordinate with various business units and departments in the development and delivery of training programs
• Develop, share, and incorporate organizational best practices into business applications
• Oversee all changes to departmental policies and procedures, including communicating and implementing the changes
• Serve as the subject matter expert on the assigned function product to ensure operational performance
• Ability to travel

Business Analyst IV – Integration Quality, User Acceptance Testing

Director

• Leads strategic business transformation programs with enterprise impact
• Acts as a trusted advisor and strategic partner to Centene leadership
• Assists with the business transformation team's strategy, execution/delivery methodology, and realizing business benefits across the enterprise portfolio
• Manages a team responsible for adhering to the department's Business Transformation Methodology
• Sources talent, coaches, trains, mentors, and provides feedback; conducts annual reviews and all matters required by HR
• Leads enterprise-wide transformation initiatives across Appeals & Grievances functions, partnering with senior leaders to standardize processes, drive governance, and improve performance outcomes
• Provides forward-thinking leadership to a team of Business Transformation Professionals in guiding the business to achieve operational efficiency
• Leverages superior knowledge of healthcare, business improvement/transformation, organization change management, customer experience, and strategy, to develop training and enforcement of the eBT methodology tools and techniques

Senior Director, Business Transformation, Appeals & Grievances

Communications

• Support the planning, development, and execution of clear, consistent, and compliant communications.
• Coordinate with subject matter experts and training teams to ensure accurate information delivery.
• Develop and distribute communication materials.
• Coordinate review and approval of communication materials with internal experts.
• Maintain knowledge of federal and state regulatory requirements for communications materials.

Senior Communications Specialist

Manager

• Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends and schemes
• Monitor business processes and systems to assure integrity and compliance in billing and claims payment
• Lead a team responsible for investigating fraud, waste and abuse referrals for prepay investigations
• Develop educational materials to address/identify waste activities as requested by the health plan and on an ad-hoc basis
• Attend state/federal meetings as required by specific contracts
• Review pre-payment cases with appropriate parties for the purposes of developing resolution strategies
• Prepare and distribute monthly and quarterly saving reports
• Participate in Appeals Committee, work groups and interdepartmental meetings

Manager, SIU Prepay Investigations

Vice President

• Responsible for developing and managing the provider network strategy for Centene Corporation
• Lead all aspects of provider network strategy including reimbursement strategy, contracting strategy, unit cost management, claims configuration and network operations
• Oversee network development staff and external consultants in the development of provider networks across expansion markets
• Lead health plans in periodic analyses of their provider networks from a cost, coverage, and growth perspective
• Provide leadership in evaluating opportunities to expand or change the network to meet Company goals
• Manage budgeting and forecasting initiatives for product lines to network costs and provider contracts
• Oversee analysis of claim trend data and/or market information to derive conclusions to support contract negotiations
• Lead initiatives to ensure periodic review of provider contracting rates to ensure strategic focus is on target with overall Company strategy
• Lead development of fee schedules and rates for new and existing markets consistent with budget and premium revenue assumptions
• Support market expansion and M&A activities by leading provider contract analysis related to due diligence
• Assist health plan CEOs, network development, legal and finance teams in key provider contract negotiations and strategy
• Work collaboratively with Business Development on new markets and new product development initiatives
• Ability to travel
• Performs other duties as assigned

Vice President, Network Strategy – Management Value-Based Contracting

Business Operations

• identifies and facilitates enterprise-wide process improvement activities utilizing LEAN/Six Sigma methodologies
• mapping processes in Visio
• assessing process/procedural documentation needs
• identifying gaps and improvement opportunities
• manages documentation repositories in a decentralized environment
• performs annual documentation reviews to ensure accuracy and compliance
• document current state process workflows and procedures
• perform needs assessment within Business teams to identify gaps in documented process and procedures
• manage process and procedural content within content management source system(s)
• identify, develop, prioritize, and execute process improvement opportunities utilizing continuous improvement principles and LEAN/Six Sigma methodologies
• provide training to project teams and functional areas to assist with the implementation and maintenance of process improvement activities
• identify, communicate, and correct gaps in process performance and provide guidance to address these gaps

Business Process Improvement Manager

Procurement

• Manage vendor relationships and ensure vendor compliance with established internal and/or regulatory performance metrics
• Accumulate, monitor, and report on vendor performance metrics to business unit management
• Communicate expectations and vendor performance against established performance metrics to vendors, including development, implementation and follow up on annual vendor goals and targets
• Ensure applicable vendor performance improvement plans and/or corrective action plans are initiated and completed as expected
• Ensure vendors sustain required performance improvements/outcomes through verification audits
• Conduct oversight meetings which include vendors, internal partners, and other stakeholders as appropriate
• Oversee health plan participation in annual delegation audits
• Provide follow-through on audit deficiencies to assure corrective actions are implemented
• Facilitate communication to/from vendors and internal partners

Director, Vendor Management

Systems Engineer

• Drives the collaboration with business and IT stakeholders to translate complex business requirements into comprehensive functional and non-functional technical specifications
• Gathers and validates business / technology requirements
• Analyzes and verifies requirements for completeness, consistency, comprehensibility, feasibility, and conformity to standards
• Translates conceptual user requirements into functional requirements
• Creates systems and business process models, specifications, diagrams, and charts
• Communicates changes, enhancements, and modifications of business requirements to stakeholders
• Plans and coordinates user acceptance testing (UAT)

Senior Business Systems Analyst

Account Manager

• Maintain partnerships between the health plan and the contracted provider networks serving our communities.
• Build client relations to ensure delivery of the highest level of care to our members.
• Engage with providers to align on network performance opportunities and solutions, and consultative account management and accountability for issue resolution.
• Drive optimal performance in contract incentive performance, quality, and cost utilization.
• Serve as primary contact for providers and act as a liaison between the providers and the health plan.
• Triages provider issues as needed for resolution to internal partners.
• Investigate, resolve and communicate provider claim issues and changes.
• Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics.
• Perform provider orientations and ongoing provider education, including writing and updating orientation materials.

Provider Engagement Account Manager

• Oversight of the Gold Card Program to ensure effective performance and communication with stakeholders
• Develop and lead long term program development and enhancement initiatives
• Ensure subject matter expertise is infused into the program
• Support the integration of the program across all business units
• Ensure consistent integration of adaptive technology and expert team-based services
• Support in the financial analysis of the program performance and strategic plans

Senior Director, Gold Card Program

Project Manager

• Provide end-to-end project management support for Contact Center Telephony initiatives
• Focus on Interactive Voice Response (IVR) systems and related technology solutions
• Translate business needs into actionable plans
• Manage risks and dependencies
• Ensure smooth implementation of innovation and system improvements
• Lead change management efforts to support adoption and sustainment of new processes, enhancements, and telephony capabilities across the organization
• Manage the full project life cycle
• Create project plans and schedules
• Manage budget and facilitate project execution, deployment, and closure
• Partner with contact center operations, IT teams, vendors, and business units to oversee program implementations
• Support rollout activities and ensure smooth adoption of new IVR features or telephony tools
• Utilize corporate and industry standard project management tools and techniques
• Assist with establishment and maintenance of corporate project management methodology and other department procedures
• Maintain detailed project documentation including meeting minutes, action items, issues lists and risk management plans
• Provide leadership and communicate project status to all stakeholders and external agencies
• Negotiate with project stakeholders to identify resources, resolve issues, and mitigate risks
• Coordinate cross-functional meetings with various functional areas to meet overall stakeholder expectations and company’s objectives
• Provide functional and technical knowledge across multiple business and technical areas
• Monitor the creation of all project deliverables to ensure adherence to quality standards including design documents, test plans, training materials, and operations documentation
• Approximately 10% travel

Project Manager IV

• Manages a team of auditors and clinical professionals and is accountable for audit quality, consistency, and overall program performance for potentially preventable readmissions.
• Oversees payer readmission review programs to ensure accurate, compliant determinations and achievement of payment integrity objectives.
• This role directs the identification and validation of potentially preventable readmissions while supporting appropriate reimbursement under MS-DRG and APR-DRG methodologies.
• Responsible for driving program results through audit oversight, trend analysis, and the development of standardized review criteria and best practices.
• Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams to support the design, execution, and ongoing monitoring of readmission and DRG-related Payment Integrity strategies.
• Monitor program performance against defined metrics, financial targets, and operational benchmarks, using trend analysis to identify risks, variances, and opportunities for improvement.
• Provide leadership and operational oversight to teams performing readmission, MS-DRG, and APR-DRG reviews, ensuring accuracy, consistency, timeliness, and adherence to established review standards.
• Ensure compliance with federal and state regulations, managed care organization requirements, contractual obligations, and internal policies governing Payment Integrity and audit activities.
• Prepare and present reports, analyses, and performance summaries to leadership and key stakeholders, highlighting audit outcomes, trends, and actionable recommendations.
• Identify process gaps, operational risks, and control weaknesses, and implement or recommend corrective actions to improve quality, efficiency, and program effectiveness.
• Lead, coach, and develop team members by setting clear expectations, promoting accountability, and fostering a culture of collaboration, quality, and continuous improvement.
• Serve as a subject matter expert for Payment Integrity practices within assigned scope, providing guidance on readmission review methodology, audit standards, and reimbursement considerations.

Manager, Payment Integrity – Readmission

• Accountable for the Medical Loss Ratio (MLR) compliance and reporting program across assigned lines of business, ensuring accurate calculation, strong governance and controls, and timely submission of federal and state filings.
• Provides strategic and operational leadership for end-to-end MLR activities, including methodology oversight, documentation standards, audit readiness, rebate execution, and regulatory examinations.
• Leads and develops a team, sets priorities and deliverables, and drives cross-functional alignment with Finance, Actuarial, Legal/Compliance, Government Affairs, and operational partners.
• Serves as the escalation point for complex interpretation and judgment matters, proactively identifies and mitigates enterprise risk, and sponsors continuous improvement initiatives that strengthen data quality, consistency, and regulatory confidence.
• Provides oversight of the MLR reporting calendar and delivery model for assigned lines of business; set expectations, assign work, and ensure filings to CMS and state regulators are accurate, complete, and submitted on time.
• Provides oversight and final review of MLR methodology, assumptions, and classifications; ensure consistent application of federal and state requirements (e.g., ACA commercial markets, Medicare Advantage, Medicaid) and alignment with internal policy.
• Leads cross-functional forums and working sessions with Finance, Actuarial, Legal/Compliance, Government Affairs, and operations to drive decisions, resolve issues, and ensure clear ownership of actions that impact MLR results and regulatory posture.
• Designs, implements, and maintains MLR governance, internal controls, and documentation standards; approve key artifacts and ensure an audit-ready trail from data sources through final filing outputs.
• Oversees MLR performance monitoring and threshold management; interprets drivers, evaluates emerging risk, and sponsors mitigation strategies and corrective action plans in partnership with business owners.
• Has oversight of MLR rebate planning and execution, including governance over inputs, leadership approvals, and downstream communications to ensure compliance with federal and state requirements and timelines.
• Establishes a risk-based monitoring and review plan; oversees deeper-dive analyses, internal audits, and control testing; ensures remediation is implemented, validated, and sustained.
• Maintains awareness of legislative and regulatory changes impacting MLR; assess impact, advise leadership on options and risk, and lead implementation of required policy, process, and control updates.
• Maintains oversight of MLR-related policies, procedures, and tools (or their enterprise alignment); set standards for accurate classification of claims, quality improvement activities, and administrative expenses, and resolve interpretation disputes.
• Serves as the primary accountable leader for regulatory inquiries, audits, and examinations related to MLR; approve responses, ensure supporting documentation quality, and coordinate cross-functional participation.
• Coaches and develops team members; provides consultation and training to stakeholders on MLR requirements, controls, and risk management expectations.
• Provides executive-ready reporting and recommendations to senior leadership and governance committees on MLR compliance status, key risks, control effectiveness, and remediation progress.
• Contributes process improvement and data governance initiatives (e.g., standardization, automation, reconciliations, evidence retention) to improve oversight, efficiency, and consistency across the MLR lifecycle.
• Performs other duties as assigned. Complies with all policies and standards.

Senior Manager, Medical Loss Ratio

• Responsible for the growth and performance of assigned mid/high complexity and revenue Medicare markets within a region
• Develop and execute market-specific strategies
• Foster cross-functional collaboration
• Develop strong internal and external partnerships with key stakeholders
• Drive operational excellence
• Manage P&L for assigned markets
• Develop market-specific strategic operating plans with KPIs, milestones, and governance processes
• Lead expansion and performance of value-based care initiatives
• Monitor and analyze the changing landscape and recommend strategies
• Drive quality initiatives aligned with STAR outcomes
• Provide effective leadership to direct and matrixed teams