Centene Corporation

Director

• Directs the organization with critical information for fact-based decisions
• Leads staff in gathering business requirements and completing reporting solutions
• Manages day-to-day functions of business and reporting analysts
• Analyzes reports and makes recommendations/explanations
• Designs and builds utilization management dashboards/reports/models
• Works with internal report production teams to evaluate performance
• Identifies and manages outside vendor relationships
• Collaborates with other teams to produce desired reporting

Director, Reporting and Analytics

Risk

• Director, Risk Adjustment responsible for driving Risk Adjustment for various lines of business and achieving related revenue targets
• Identify opportunities to improve completeness and accuracy of risk adjustment data submitted to CMS and HHS
• Develop, analyze and report key risk adjustment metrics
• Oversee analyses of new legislation and regulations regarding Risk Adjustment and assess impact on programs
• Partner with executive leadership to plan strategic direction of Risk Adjustment initiatives
• Evaluate and oversee development and implementation of CMS and HHS risk adjustment program changes
• Incorporate changes and requirements into strategy
• Coordinate with functional areas including Medical Management, Quality, Pharmacy, Operations, etc.
• Use analytics to define Risk Adjustment focus
• Identify areas to increase quality and maximize opportunities
• Direct development of key analytics and data to support Risk Adjustment forecasts and reporting
• Educate stakeholders on changes in regulations and recommend areas of process improvement
• Maximize ROI in Risk Adjustment operations by reducing reliance on vendors
• Maintain effective and optimal Risk Adjustment submission process and Quality Assurance Program
• Monitor, measure and communicate Risk Adjustment performance and submission quality
• Develop performance targets for constituents and track progress against stated goals
• Serve as subject matter expert in projects and initiatives
• Drive Risk Adjustment best practices across all lines of business
• Develop and implement employee training and provider outreach programs as needed

Director, Risk Adjustment

Account Manager

• Manage client accounts through implementation and assigned accounts
• Resolve day to day issues for clients and assist Account Executive on aspects of supporting client specific strategic plans
• Serve as the day-to-day contact for assigned accounts, interacting with client contacts to facilitate problem resolution and promote high client satisfaction
• Work cross functionally with internal departments regarding client needs and requests, contractual obligations, work procedures, benefit change requests, and other elements of supporting assigned clients
• Assist the Account Executive with account renewals, benefit enrollment meetings, and overall compliance with client contracts
• Manage plan setup and benefit configuration of new and existing clients in PBM system
• Participate in new client implementation meetings, finalists meetings, conferences and tradeshows
• Develop contract amendments under the direction of the Account Executive
• Document appropriate client specific information in Salesforce.com
• Ability to travel
• Performs other duties as assigned
• Complies with all policies and standards

Manager

• Manage provider networks for adequacy and access
• Conduct high level negotiations and renegotiations of provider contracts
• Monitor network adequacy and resolves hospital provider claim issues
• Provide regional input and maintenance of provider directory listings
• Participate in monthly internal/external meetings involving network activity
• Monitor areas credentialing process
• Develop provider contracting strategy
• Oversee network development and retention strategizing
• Oversee network problem resolution (Claims, UM, Etc.)
• Oversee network analysis for adequacy and recruitment targets
• Oversee provider contract negotiations – hospitals, ancillaries, and groups
• Provide financial analysis for network development targets
• Perform other duties as assigned
• Complies with all policies and standards

Provider Network Manager

Analyst

• Support market development analysis on various initiatives
• Perform competitive analysis and industry research to support market strategy and growth for line of business
• Track and update market environment activity including industry trends, competitor information, and acquisitions in related industries
• Perform qualitative and quantitative analysis of opportunities including financial projections
• Identify potential growth and expansion opportunities by retrieving, organizing, and analyzing market conditions including industry trends, competitor information and acquisitions from online sources, external literature, internal data, legislative decisions and regulatory activity
• Provide forecasts and reports of relevant market trends
• Support market segmentation, business plan development, and performance analysis and evaluation
• Support development of growth plan for business lines, for Individual, Small Group, and Large Group commercial business lines
• Performs other duties as assigned
• Complies with all policies and standards

Market Strategy Analyst

Data Analyst

• Analyze integrated and extensive datasets to extract value.
• 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.
• Interpret and analyze data from multiple sources including healthcare provider, member/patient, and third-party data.
• Support execution of large-scale projects with limited direction from leadership.
• 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.
• Support the design, testing, and implementation of process enhancements and identify opportunities for automation.
• Apply expertise in quantitative analysis, data mining, and the presentation of data to see beyond the numbers.
• Support multiple functions and levels of the organization and effectively communicate findings 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 stakeholders, soliciting and incorporating feedback when required.

Data Analyst II – Automation Analytics

Compliance

• Ensure compliance with State contract and regulatory reporting and deliverable submission, and tracking and recordkeeping
• Oversee and monitor HIPAA privacy regulation, special project assignments and compliance training company wide
• Ensure timely state deliverable submission, accuracy of reports, and tracking and recordkeeping of State deliverables
• Update and maintain deliverable matrices/tracking reports for Health Plan and delegated subcontractors
• Lead special projects related to Access and miscellaneous reporting
• Provide reports required for HMO license maintenance, as required by the Department of Insurance
• Develop and deliver compliance training annually for all employees
• Proactively identify and mitigate compliance risks related to State contract and regulatory reporting and deliverables
• Lead HIPAA privacy monitoring and oversight, to include quarterly desk audits and collaboration with department managers to address noncompliance

Lead Compliance Coordinator

• Serve as the single point of contact for assigned Medical Director’s Office (MDO).
• Provide direction and guidance to existing MDO related to any questions or issues.
• Maintain and expand strong relationships with MDO to support overall account management and operational needs.
• Assess and maintain client satisfaction by implementing action plans to uphold high levels of quality service.
• Collaborate with various departments to identify, investigate, and resolve MDO inquiries and escalations.
• Coordinate and identify training opportunities for sales and operations departments to enhance performance and customer satisfaction.
• Assist Account Executives to identify and generate new sales opportunities within existing accounts.

Provider Experience Manager

Operations

• Provides direct supervision to entry and/or processing staff
• Monitors and directs workflow to ensure timely and accurate processing
• Develops policies and procedures to improve efficiencies
• Interfaces with internal staff, field personnel, and customers
• Creates and monitors reports for process control and production effectiveness
• Handles escalated telephone calls

Supervisor, Operations

• 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.
• Receive and effectively respond to external provider related issues.
• Investigate, resolve and communicate provider claim issues and changes.
• Initiate data entry of provider-related demographic information 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.
• Manages Network performance for assigned territory through a consultative/account management approach.
• Evaluates provider performance and develops strategic plan to improve performance.
• Completes special projects as assigned.

Provider Engagement Account Manager

Architect

• Leads the design, implementation, and communication of enterprise business continuity and disaster recovery plans and processes
• Conducts enterprise risk analysis to identify critical operations and systems
• Monitors and tests the plans and backup systems
• Develops and deploys training, documentation, and communication of disaster procedures to the organization
• Completes IT DR recovery procedures and work with technical teams to co-create IT DR recovery strategies, architectures and procedures
• Manages the IT DR calendar, incorporating the activities designed to monitor the effectiveness of the IT DR framework

Senior Disaster Recovery Architect

Medical Reviewer

• Supports peer-to-peer (P2P) processes, including scheduling P2P between Medical Directors and providers according to internal policies and requirements.
• Manages and reviews Medical Director’s workflow queue in the medical management system and adjusts workflows as needed based on escalations and scheduling.
• Schedules peer-to-peer (P2P) between Medical Directors and providers to discuss clinical services including the approval of a prior authorization.
• Manages turn-around times for P2P authorizations to ensure P2P are conducted within a timely manner in accordance with regulations and policies.
• Develops in-depth knowledge of P2P process, best practices, and internal policies and requirements.
• Serves as front-line support in communicating with providers and/or vendors.
• Provides support with all communications between clinical staff, providers, and Medical Directors.
• Works with different teams to identify process improvements and efficiencies within the P2P process.
• Performs other duties as assigned.
• Complies with all policies and standards.

Medical Review Specialist III

• Monitor compliance
• Drive remediation of variances
• Generate responses for multiple audits
• Prepare various reports on audit findings
• Recommend improvements in policies, procedures and internal controls
• Establish appropriate internal controls
• Ensure alignment with regulatory requirements
• Monitor and assist in external audits of organization
• Review and assess complaints from various agencies
• Gather and analyze responses and follow up with agencies
• Identify root cause of complaints
• Implement changes to address issues
• Assist in developing and implementing audit programs
• Summarize audit conclusion and key findings into the audit repository

Auditing Analyst

• Develop and direct strategic business initiatives within product offerings, management, development, and enhancement
• Ensure subject matter expertise is infused into all products
• Identify and support the integration of duplicative products/interventions across all business units
• Ensure consistent and seamless integration of adaptive technology and expert team-based services across all product portfolios
• Support sales and client services across all business units with product customization
• Support in the financial analysis of product performance

Senior Director, Provider Digital & Interoperability Initiatives

• Assists in developing, assessing, and coordinating holistic care management activities
• May develop or assist with developing personalized service care plans/service plans for long-term care members
• Educates members and their families/caregivers on services and benefits available
• Evaluates the needs of the member and the resources available
• Recommends and/or facilitates the plan for the best outcome
• Coordinates as appropriate between the member and/or family/caregivers and the care provider team
• Provides resource support to members and their families/caregivers for various needs
• Monitors care plans/service plans, member status and outcomes
• Interacts with long-term care healthcare providers and partners
• Collects, documents, and maintains long-term care member information
• Performs home and/or other site visits to assess member’s needs
• Provides and/or facilitates education to long-term care members and their families/caregivers
• Provides feedback to leadership on opportunities to improve and enhance quality of care and service delivery