Centene Corporation

Operations

• Lead and direct process improvement initiatives by utilizing process improvement methodologies in the analysis of current operations and design of improvement projects across all areas that impact operations
• Support NCQA HEDIS audit readiness and compliance, ensuring accurate and timely submissions
• Lead daily audit readiness activities, including Roadmaps, Section 5 documentation, Measure Specifications, CAHPS coordination, and auditor engagement
• Oversee the administration, coordination and evaluation of quality assurance and training
• Direct the execution of performance improvement projects, including process mapping and process design including HEDIS audit timelines and deliverables
• Serve as primary point of contact for auditors and leadership, supporting audit communications and successful outcomes
• Create and maintain dashboards, communications, and strategies to improve effectiveness
• Research and develop best practices, policies, procedures, and goals in compliance with internal and external guidelines
• Oversee data analysis and gathering processes and programs to establish costs and benefits of process effectiveness and efficiency
• Ensure business unit is compliant with URAC and Joint Commission Accreditation standards
• Review and implement new technological tools and processes
• Establish strong collaborative relationships with all functional units and their leaders

Director, Quality & Process Improvement, HEDIS Audit

Pharmacist

• Act as a subject matter expert on complex pharmacy issues
• Respond to escalated calls from members, provider/physician's offices, and pharmacies
• Make outbound calls and enter pharmacy overrides into systems
• Take member/prescriber/pharmacist inquiry calls for benefit questions
• Offer options including submission of prior authorization requests
• Research issues and take appropriate action to resolve them
• Conduct inbound and outbound calls for claims resolution
• Assist team members in guiding them to appropriate resolution of inquiries
• Participate in training less experienced staff
• Act as a liaison between internal departments for data gathering and problem solving
• Present proposed solutions clearly
• Assist with audit preparation and special project work as assigned
• Comply with all policies and standards

Senior Pharmacy Resolution Specialist

Data Analyst

• Responsible for analytic data needs of the business unit
• Handle complex data projects and acts as a lead for other Data Analysts
• Provide advanced analytical support for business operations in various areas
• Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources
• Review data to determine operational impacts and needed actions
• Develop reports and deliverables and make recommendations to management
• Assist management in driving business decisions based on data
• Ensure compliance with federal and state deliverable reporting requirements by performing data quality audits and analyses
• Assist with training and mentoring other Data Analysts
• Performs other duties as assigned

Data Analyst IV, Provider Data, SQL

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, ensuring timely and quality decision making
• 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 in accordance with regulatory, state, corporate, and accreditation requirements
• Assists the Chief Medical Director 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
• 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

Therapist

• Performs clinical reviews of clinical therapy services and/or durable medical equipment to members based on service request assessments
• Provides clinical expertise based on practice standards
• Works with senior management to identify ways to improve the review and execution of therapy services based on clinical reviews of service request assessments
• Performs utilization reviews of service requests regarding specialty therapy services and/or durable medical equipment for members based on best practice and documentation standards by the national therapy associations and organizational policies
• Provides recommendations for therapy determinations and refers members to care management, as appropriate, based on service request assessments
• Works with Utilization and Care Management teams and healthcare providers to ensure members are receiving the appropriate care and treatment
• Expands therapy specialty knowledge and works with senior management to identify areas of improvement with therapy services and/or durable medical equipment for members
• Assists with providing education including developing clinical trainings, consultations, and guidance related to therapy authorizations and/or durable medical equipment
• Provides feedback to leadership on opportunities to improve the review and therapy services and/or durable medical equipment outcomes to members based on standards and organizational policies
• Performs other duties as assigned
• Complies with all policies and standards

Clinical Review Therapist – Physical Health

Data Scientist

• Lead the enterprise strategy for clinical data science, including predictive modeling, machine learning innovation, and causal evaluation of clinical programs.
• Develop and deploy advanced models that identify, stratify, and prioritize members for clinical and care management interventions.
• Oversee development of models for high-risk and rising-risk identification, avoidable utilization, chronic condition progression, and care management prioritization.
• Advance the organization’s AI capabilities by applying modern machine learning approaches, including deep learning and transformer-based models, to large healthcare datasets.
• Partner with clinical, operational, actuarial, and analytics leaders to translate business and clinical priorities into scalable data science solutions.
• Establish standards for model governance, monitoring, and performance management to ensure regulatory compliance, fairness, and responsible AI practices.
• Build, lead, and mentor a high-performing team of data scientists.

Senior Director, Clinical Data Science

Marketing

• Manage all activities related to marketing, communications, preventive health education and product- or market-specific consumer experience initiatives
• Provide strategic marketing and communications solutions to meet business objectives and timelines
• Oversee the writing, design and production of member and provider materials including newsletters, educational materials, handbooks, directories, manuals, member ID cards, promotional advertising, and website content while maintaining Corporate brand and style guidelines and state compliance requirements
• Own end‑to‑end AEP readiness and execution across assigned lines of business, materials, and workstreams, ensuring all outputs are delivered on time, accurate, and compliant with regulatory, operational, and business requirements, while serving as the single point of accountability for AEP delivery from intake through final fulfillment
• Lead, develop, and implement product and/or health plan strategic marketing plans, including traditional and non-traditional channels, community outreach, and related initiatives to grow and retain membership
• Oversee the development, coordination and production of marketing activities
• Develop strategic marketing measurement plans to effectively assess performance of marketing and communications activities
• Produce accurate and timely reports needed for contractual or business needs
• Identify department and project needs, with continuous development of process and procedures to drive effectiveness
• Build and maintain internal and external business relationships

Senior Manager, Marketing

Business Analyst

• Perform various analysis and interpretation to link business needs and objectives for assigned function
• Map provider source documents to directory outputs to ensure accurate data display
• Conduct Excel‑based reconciliation and validation of source‑to‑output data
• Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems
• Identify and analyze user requirements, procedures, and problems to improve existing processes
• Perform detailed analysis on assigned projects, recommend potential business solutions and assist with implementation
• Identify ways to enhance performance management and operational reports related to new business implementation processes
• Develop and incorporate organizational best practices into business applications
• Lead problem solving and coordination efforts between various business units

Business Analyst II – Provider Data Operations

• responsible for managing, directing and supporting the dental operations for our Medi-Cal, Healthy Families and Medicare members.
• ensuring compliance with Department of Health Services (DHS) and Healthy Families MRMIB contracts.
• monitors Health Net's performance under its dental services contracts with the State.
• oversees Health Net's dental administration functions performed by the designated third party administrator.
• maintains and expands provider network through contract negotiations and execution.
• works closely with Dental Director to ensure that the dental care provided meets the standards for acceptable dental care.
• performs utilization review by reviewing claims and encounter data.
• develops and implements policies and procedures for the dental plan.
• assists in grievance resolution related to quality of care under the dental plan.
• actively participates in plan grievance procedures under the dental plan.

Dental Operations Manager

Chief Operating Officer

• Accountability for the day to day operations, profitability and growth
• Ensure that the customers' needs are well served
• Develop relationships with network providers, area employers, and contractors; ensure successful development and implementation of business plans
• Develop and implement strategic and tactical plans to ensure further growth and development of the business unit and ensure positive financial results
• Oversee development and execution of operating plans, including employee development, organization goals, and member and provider relations goals
• Establish criteria for measuring and assessing the success/performance of each component of operation
• Ensure appropriate provider network is developed and maintained
• Develop effective relationships with key stakeholders to educate providers and consumers on necessary topics
• Develop and establish operational mission statements, philosophy, policies, goals, objectives and strategy
• Provide management all necessary contractual requirement information regarding state and federal regulatory agencies

• 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, ensuring timely and quality decision making.
• 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 in accordance with regulatory, state, corporate, and accreditation requirements.
• Assists the Chief Medical Director 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.
• 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.

Claims Specialist

• Ensure timely processing of pending medical claims
• Verify and update information on the submitted claims
• Review work processes to determine reimbursement eligibility
• Ensure payments and/or denials are made in accordance with company protocols and procedures
• Process first time claims
• Apply policy and provider contract provisions to determine if claim is payable
• Research and determine status of medical related claims
• Maintain records, files, and documentation as appropriate
• Meet and maintain department production and quality standards
• Successfully complete additional progressive claims training programs as required
• Performs other duties as assigned
• Complies with all policies and standards

Claims Analyst

Product Designer

• Executes the structure and flow of a digital solution (website, app, software, mobile, etc.)
• Maps how the end-user interacts with the product and develops a structure, including layouts and flows
• Executes the UX experiences that are clear and easy to understand
• Facilitates internal workshops and presentations for digital products regarding design thinking
• Outlines and researches user industry-wide information to uncover insights and improve the effectiveness of our products
• Implements design concepts and experiences for websites
• Coaches Product Designers on design experience methodologies and approaches
• Analyzes current and potential websites to provide actionable recommendations
• Collaborates with cross-functional teams and clients to define, design, deploy, and test user interface enhancements
• Creates deliverables that communicate proposed user experience designs effectively

UX Architect

Program Manager

• Identify opportunities to increase efficiency, improve service levels, and ensure regulatory and PA compliance through enhanced, standardized operations and governance practices
• Develop and execute strategies to realize PA improvement opportunities, ensuring enterprise‑level prioritization, clear decision rights, and appropriate resource alignment
• Manage multiple PA initiatives through the full project lifecycle
• Support structured PA governance cycles by ensuring initiatives are evaluated, prioritized, approved, and sequenced
• Utilize corporate and industry‑standard project management and governance tools to manage PA initiatives effectively
• Maintain detailed and accurate PA program documentation
• Compile, format, and validate review packets and governance decision materials for leadership review
• Coordinate and validate market, clinical, and SME inputs for PA governance materials
• Partner with analytics, medical economics, and operations teams to review financial and operational claims data
• Ensure ad‑hoc PA requests are logged, tracked, prioritized, and either executed or formally deferred
• Maintain a centralized PA documentation repository as the single source of truth for governance artifacts
• Provide strong leadership and communicate PA program and governance status to stakeholders
• Lead cross‑functional governance and working sessions to meet enterprise objectives and stakeholder expectations
• Negotiate with stakeholders to secure resources, resolve cross‑functional dependencies, and mitigate risks

Program Manager – PA Governance

• receives and responds to calls from members, provider/physician's offices, and pharmacies
• makes outbound calls and enters pharmacy overrides into systems based on approved guidelines
• takes member/prescriber/pharmacist inquiry calls for benefit questions
• offers options including submission of a prior authorization request
• thoroughly researches issues and takes appropriate action to resolve them
• logs, tracks, resolves, and responds to all assigned inquiries and complaints
• maintains expert knowledge on all pharmacy benefits and formularies
• answers and conducts inbound and outbound calls with members and provider offices
• actively involved in the initiation and providing status for prior authorization/coverage determination
• identifies root cause issues to ensure enterprise solutions
• assists with special projects as assigned