Centene Corporation

Business Analyst

• Perform various analysis and interpretation to link business needs and objectives for assigned function
• 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
• Assist with formulating and updating departmental policies and procedures
• Performs other duties as assigned
• Complies with all policies and standards

Business Analyst II – Integration Quality, User Acceptance Testing

• 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

Manager

• manage a team of user acceptance testing professionals
• ensure delivery and testing solutions or procedures are consistent with business expectations
• provide business and User Acceptance Testing expertise and guidance
• manage a team that supports PHCO and Enterprise initiatives
• proactively inform requirements, workflows, procedures to improve existing processes
• negotiate and work with business and project leaders to identify appropriate support
• collaborate with other leaders to ensure delivery and results meet business needs
• provide oversight and guidance for testing best practices, tools, procedures, and test automation
• develop standards and SLAs for various testing processes
• prepare reports and/or necessary testing documentation and results and present it to applicable internal and external stakeholders
• manage hiring and training of new and existing staff
• conduct performance reviews, provide leadership, and technical and testing guidance and coaching
• communicate business need and testing results to technical and business stakeholders
• participate and lead discussions related to root cause and resolutions for various business problems
• build and maintain best-in-class testing practice with the ability to scale

Manager, Integration Quality – User Acceptance Testing

Director

• Provide strategic leadership for the Audit Programs function within Payment Integrity
• Lead the design, execution, and continuous optimization of prepayment and post payment audit programs that improve claims accuracy, reduce improper payments, and strengthen payment controls across all applicable lines of business
• Establish the audit program roadmap, governance, methodologies, and performance standards
• Oversee internal teams and external partners
• Partner across the enterprise to implement solutions that deliver sustainable medical cost savings and operational excellence
• Oversee clinical, coding, pricing, and policy audit activities to reduce improper payments and improve claims accuracy
• Lead the identification, prioritization, and execution of audit opportunities aligned with financial and operational goals
• Establish performance standards, metrics, and reporting to monitor audit effectiveness, savings, and operational health
• Leverage data and analytics to identify trends, risks, and root causes of payment errors
• Serve as a senior escalation point for complex audit findings, provider disputes, and operational challenges
• Oversee external vendors supporting audit and recovery activities, ensuring quality, compliance, and performance accountability
• Communicate audit results, risks, and recommendations clearly to senior leadership
• Lead, develop, and mentor audit and clinical teams, fostering a culture of accountability and continuous improvement

Senior Director, Payment Integrity – Audit Programs

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
• Triage 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
• Drive optimal performance in contract incentive performance, quality, and cost utilization
• Manage network performance for assigned territory through a consultative/account management approach

Provider Engagement Account Manager

Data Analyst

• Support analytic data needs for assigned business unit
• Handle complex data requests and acts as a “go to” person for other Data Analysts
• Identify and prioritize recurring and ad hoc data analysis needs
• Enable management to control medical costs
• Ensure delivery of quality healthcare to members
• Coordinate analysis and development initiatives with cross health plan initiatives and capabilities
• Perform analysis and reporting to support the Health Plan and Corporate
• Manage development efforts with technical team liaisons
• Including business requirements gathering and documentation
• testing
• delivery and user adoption
• Effectively communicate deliverable expectations to the Health Plan
• Analyze plan data including service and clinical and trend analysis
• Develop reports through various data reporting tools
• Manage
• mentor
• and train team of analysts
• Use ServiceNow to intake
• track
• and resolve requests/issues; maintain clear documentation and stakeholder updates
• Promote SQL querying standards and knowledge sharing across the team; support peer reviews and reusable query patterns

Manager, Data Analysis

• Perform various analysis and interpretation to link business needs and objectives for assigned function.
• Lead analysis for high-priority, escalation-driven initiatives for the Clinical Systems Enablement Team.
• Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems.
• Identify ways to enhance performance management and operational reports related to new business implementation processes.
• Lead problem solving and coordination efforts between various business units.

Business Analyst II, Clinical Technology Special Projects

Customer Support

• Assisting members and clients at an assigned Fidelis Care office location
• Meeting daily performance standards and customer service standards
• Educating and resolving client and member inquiries
• Enrolling prospective members and renewing member coverage
• Logging every interaction into Salesforce
• Complying with all NYSOH Marketing Guidelines and all Fidelis and Centene trainings
• Clarifying the customer's complaint and determining the cause of the problem
• Developing and maintaining relationships with existing members

Bilingual Customer Care Associate

Support Engineer

• Provides in-depth business knowledge and advanced technical support to one or more business areas
• Acts as subject matter expert for department or business unit on business systems/applications
• Analyzes company functions, processes, and activities to improve computer-based business applications
• Performs application/system design and implementation
• Documents development requirements
• Consults with end users to test and debug applications
• Develops ad-hoc reports to conduct data analysis and validation
• Confers with area/department to analyze current operational procedures and trends
• Conducts business analysis and recommends technical alternative solutions to management
• Research, evaluate and assess the financial impact of issues identified in data/processes
• Creates multiuser, real-time, robust database solutions
• Provides oversight and resolves complex issues, optimizing performance and resolving problems
• Provides guidance and training to staff on process, procedures and issue resolution

Senior Business Technical Analyst

Operations

• Review claims for adjudication, adjustment, billing, coding, compliance and reimbursement
• Review, process and resolve pending medical, hospital and prescription claims
• Maintain appropriate records, files, documentation, etc.
• Enter manual claims into claims system
• Work mandatory overtime as needed

Claims Examiner I – Ops

• Responsible for ensuring accurate, timely, and efficient reporting and input of data related to all core business functions
• Perform business analysis, identify root cause, and develop recommendations and solutions to drive business improvements
• Collaborate across departments to develop and implement improved workflows and processes
• Ensure the timeliness and accuracy of internal and external report deliverables
• Manage scheduled and ad hoc reporting needs of the organization
• Execute and manage the completion of large reconciliation tasks
• Responsible for the quality and completeness of data in core systems by performing and overseeing the auditing of data
• Oversee large systems and data related projects
• Mentor and manage a team of data analysts of variable skill and practice levels
• Lead and execute complex data related analytical projects to drive business decisions and efficiencies

Senior Manager, Data Analytics, Reporting

Vice President

• Direct the provider network and contracting activities
• Lead provider network strategy including access analysis, network operations, and support decision makers with analysis related to reimbursement and unit cost management
• Oversee the coordination and negotiation for the contracting department
• Establish department’s strategic vision, objectives, and policies and procedures
• Develop, implement, and maintain production and quality standards for the Contracting department
• Oversee network development staff and external consultants in the development of provider networks across expansion markets
• Perform periodic analyses of the provider network 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 networks costs and provider contracts
• Oversee analysis of claim trend data and/or market information to derive conclusions to support contract negotiations
• Conduct periodic review of provider contracting rates to ensure strategic focus is on target with overall Company strategy
• Support market expansion and M&A activities by leading provider contract analysis related to due diligence
• Assist health plan CEO and/or COO vendors in key provider relations and strategy
• Ability to travel

Vice President, Network Development – Contracting

• Develop, implement and manage strategic fraud, waste and abuse activities for our Arizona and Nevada markets
• Monitor business processes and systems to assure integrity and compliance in billing and claims payment
• Lead a team appropriately investigate all possible fraud, waste and abuse referrals
• Develop educational materials to address/identify waste activities as requested by the health plan
• Attend state/federal meetings as required by specific contracts
• Review post-payment cases with appropriate parties to obtain refund
• Prepare and distribute monthly and quarterly saving reports
• Participate in Appeals Committee, work groups and interdepartmental meetings

Manager, Special Investigation Unit – SIU

• Directs the day-to-day responsibilities of a team focused on creating Enterprise-class data assets reports, visualizations, dashboards, and metrics that provide business insight and aid business decision-making
• Partners with stakeholders to identify business requirements, prioritize requirements based on resources (budget/timeline) and manage the end-to-end design and development of solutions
• Manages the development of data solutions from beginning to end of the software/solution development life cycle (SDLC)
• Develops and communicates organizational objectives; inspires and motivates team members to achieve results
• Shares knowledge and develops staff capabilities to strengthen understanding of business issues and best practices

Director, Data Consumption Enablement

Data Scientist

• Designs and develops scalable solutions using AI tools and machine-learning models.
• Performs research and testing to develop machine learning algorithms and predictive models.
• Utilizes big data computation and storage tools to create prototypes and datasets.
• Conducts model training and evaluation.
• Integrates, tests, tunes, and monitors solutions.
• Participates in model brainstorming conversations with potential internal customers interested in AI/ML capabilities.
• Analyzes use cases of ML algorithms and applies findings to enable business decisions by deriving insights through data visualization.
• Writing moderately complex SQL and Python/R code to extract data from databases and data sources.
• Explores and visualizes data to verify data quality and ensure data quality via data cleaning.
• Builds ML/AI models using common methods within R and Python.
• Analyzes ML algorithms that could be used to solve problems and rank them by success probability.
• Develops logging, alerting, and strategies for handling model errors.
• Produces fairness review for each developed model.
• Sets up continuous integration/continuous deployment (CI/CD) pipelines used for model automation.
• Produces clean & readable code that has been correctly unit tested and optimized for performance.
• Completes deployment integration testing to ensure seamless deployment.
• Maintains and supports AI/ML patterns by reviewing and solving issues and running ML/AI models.
• Assists in leading team-wide initiatives that help develop templates and define best practices to improve model building and deployment workflow.