Centene Corporation

Manager

• Develop, assess, and coordinate holistic care management activities for long-term care members
• Develop or assist with personalized service care plans and educate members and caregivers on available services and benefits
• Evaluate member needs and available resources, and recommend or facilitate appropriate care plans
• Identify providers, specialists, and community resources needed for long-term care
• Coordinate between members, caregivers, and care provider teams to ensure services are accessible
• Provide resource support involving employment, housing, participant direction, independent living, justice, foster care, and related needs
• Monitor care plans, member status, and outcomes, and recommend updates based on identified needs
• Interact with long-term care healthcare providers and partners
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Perform home and/or other site visits to assess member needs and collaborate with providers and partners
• Facilitate education on procedures, healthcare provider instructions, service options, referrals, and healthcare benefits
• Provide leadership feedback on opportunities to improve quality of care and cost-effective service delivery
• Perform other duties as assigned and comply with policies and standards

LTSS Service Care Manager

Advocate

• Act as an advocate for members and liaison between the Health Plan and providers to ensure availability and access to care
• Establish a community presence and promote member education
• Identify and resolve systemic barriers limiting access to appropriate care
• Receive and respond to member complaints and formal grievances
• Serve as primary contact and liaison between member advocacy groups, human services agencies, providers and State entities
• Evaluate member qualifications for better benefit entitlement programs
• Conduct field trainings and face-to-face meetings with providers, members and community agencies
• Report results to senior management and recommend needed resolutions
• Recommend internal process changes to improve provider and member satisfaction
• Advise the Health Plan on contract compliance in delivery of covered services
• Perform training, orientation and coaching for performance improvement
• Educate members and providers on benefits-related policies and procedures, website promotion and education
• Investigate and resolve access and cultural sensitivity issues
• Participate in local community coalitions
• Update and revise educational materials as appropriate
• Perform other duties as assigned
• Comply with all policies and standards

Member Advocate II

Care Coordinator

• Develop, assess, and coordinate holistic care management activities to support quality, cost-effective healthcare outcomes
• Develop or assist with personalized service care plans for long-term care members
• Educate members and families/caregivers about services, benefits, procedures, healthcare instructions, referrals, and service options
• Evaluate member needs and available resources, and facilitate appropriate care plans
• Identify providers, specialists, community resources, and durable medical equipment services
• Coordinate between members/families/caregivers and care provider teams to ensure services are accessible
• Provide resource support related to employment, housing, participant direction, independent living, justice, and foster care
• Monitor care plans, member status, and outcomes; recommend updates based on member needs
• Interact with long-term care providers and partners to ensure member needs are met
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Perform in-home or on-site visits to assess member needs and collaborate with providers and resources
• Provide feedback to leadership on opportunities to improve quality and cost-effective service delivery
• Perform other duties as assigned and comply with policies and standards

LTSS Service Care Coordinator

Risk

• Lead enterprise Prior Authorization governance strategy across Medicare, Medicaid, Marketplace, Commercial, and Duals populations
• Oversee governance structures, decision-making frameworks, and approval processes for Prior Authorization requirement changes
• Direct semi-annual and annual enterprise reviews of PA rules, code lists, and authorization requirements
• Ensure PA criteria align with evidence-based medicine, clinical best practices, and organizational goals
• Partner with Compliance, Legal, Medical Affairs, and Market Leadership to assess regulatory impacts and mitigation strategies
• Support Mental Health Parity and other regulatory reviews requiring PA governance oversight
• Analyze emerging trends and identify opportunities to improve effectiveness and administrative simplification
• Monitor impacts of PA policy changes and recommend corrective actions
• Sponsor data-driven decision-making and continuous improvement initiatives
• Lead collaboration across Clinical Operations, Behavioral Health, Medical Affairs, Technology, Compliance, Finance, Analytics, Pharmacy, Market Operations, and Provider teams
• Develop and mentor leaders responsible for governance, optimization, and program execution
• Lead enterprise PA optimization initiatives to reduce administrative burden and improve member and provider experience
• Support digital utilization management strategies, automation initiatives, and AI-enabled review capabilities

Senior Director, Prior Authorization Governance

Auditor

• Audit systems entry, performance metrics, and work processes for assigned functions
• Audit accuracy of new group set-ups, existing contract changes, and group terminations
• Design, implement, and manage data review processes for PDM/Credentialing data reports
• Execute risk-based audits evaluating controls and processes for scalability, efficiency, and risk mitigation
• Compile audit findings and report to management with recommendations for operational, system, and procedural improvements
• Ensure defined goals are implemented and supporting documents are available to measure performance
• Coordinate auditing outcomes to develop and publish corrective actions and educational materials related to audit errors
• Examine and evaluate information systems and recommend controls for system reliability and data integrity
• Identify and resolve system issues involving data loads
• Research state contract requirements and accrediting body standards to identify potential risks
• Perform other assigned duties and comply with policies and standards

Operations Auditor

• Provide leadership and direction for continuous quality improvement initiatives
• Improve efficiency, processes, quality of care, and services
• Provide and analyze reports to identify trends and opportunities
• Recommend initiatives to improve quality of care and services
• Oversee NCQA accreditation and compliance with contractual requirements
• Coordinate company-wide quality assessment and improvement activities
• Coordinate annual file audits and other quality-related initiatives with Corporate
• Manage and implement work tools, processes, reports, and audit tools
• Recommend quality improvement opportunities and develop and implement solutions with management, the Quality Improvement Committee, and other committees
• Provide feedback to rectify errors and prevent further inconsistencies
• Oversee monthly and quarterly reports and data to identify trends, improvement opportunities, and interventions
• Maintain policies and operating procedures and align goals with internal and external guidelines

Senior Manager, Quality Improvement

Clinician

• Perform clinical reviews and assess care related to mental health and substance abuse
• Monitor and determine whether levels of care and services are medically appropriate
• Evaluate member treatment before, during, and after services
• Perform prior authorization reviews according to regulatory guidelines and criteria
• Conduct concurrent reviews of behavioral health inpatient care, including treatment needs and discharge planning
• Analyze behavioral health member data to improve quality and appropriate utilization
• Educate providers, members, and families about the behavioral health utilization process
• Discuss levels of care and services with behavioral health healthcare providers
• Engage medical directors and leadership to improve care quality and efficiency
• Formulate and present cases in staffing and integrated rounds
• Comply with policies and standards and perform other assigned duties

Utilization Review Clinician – Behavioral Health

Full-stack Engineer

• Lead Identity and Access Management systems and solutions
• Support Production SailPoint IdentityIQ and IdentityNow solutions
• Review system, user, and administrative roles and accounts to understand enterprise access levels
• Design, build, test, and maintain scalable software applications and custom IAM solutions
• Lead cross-functional teams through the implementation process
• Enforce identity lifecycle management policies and procedures
• Identify code deficiencies, review logs, research errors, and replicate issues
• Analyze, design, develop, implement, and support identity-related software application areas and identity governance
• Review IAM technical requirements, designs, infrastructure, and support-process documentation
• Liaise with information security, risk management, infrastructure, architecture, and business teams to implement end-to-end IAM solutions
• Lead IAM technical strategies, designs, standards, and procedures
• Code, configure, test, and document IAM developments
• Troubleshoot and solve security-focused IAM issues
• Ensure compliance with corporate policies, ethical practices, and regulatory guidelines
• Perform other assigned duties and comply with policies and standards

Lead IAM Engineer

Business Intelligence Developer

• Handle complex data projects and act as a lead for other Data Analysts
• Provide advanced analytical support for business operations across claims, provider data, member data, clinical data, HEDIS, pharmacy, and external reporting
• Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources
• Review data to determine operational impacts and needed actions
• Elevate issues, trends, areas for improvement, and opportunities to management
• Develop reports and deliverables for management
• Model data using MS Excel, Access, SQL, and/or other data warehouse analytical tools
• Perform data quality audits and analysis to ensure compliance with federal and state deliverable reporting requirements
• Assist with training and mentoring other Data Analysts
• Perform other duties as assigned
• Comply with all policies and standards

Provider Data Analyst III, SQL, Power BI

• Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy
• Manage a team of auditors and clinical professionals and oversee audit quality, consistency, and program performance
• Oversee payer readmission review programs for accurate, compliant determinations and payment integrity objectives
• Direct identification and validation of potentially preventable readmissions under MS-DRG and APR-DRG methodologies
• Drive program results through audit oversight, trend analysis, standardized review criteria, and best practices
• Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams
• Monitor metrics, financial targets, operational benchmarks, risks, variances, and improvement opportunities
• Provide operational oversight for readmission, MS-DRG, and APR-DRG review teams
• Ensure compliance with regulations, managed care requirements, contracts, and internal policies
• Prepare and present reports, analyses, and performance summaries to leadership and stakeholders
• Identify process gaps, operational risks, and control weaknesses and implement or recommend corrective actions
• Lead, coach, and develop team members
• Serve as a Payment Integrity subject matter expert
• Perform other duties as assigned and comply with policies and standards

RN Readmission Manager, Payment Integrity

Backend Engineer

• Handle complex data requests, reports, and predictive data modeling
• Analyze health management programs, including data collection, validation, and outcome measurement
• Analyze financial, pharmacy, claims, provider, and member data
• Perform internal data cleansing and data reconciliation analysis
• Conduct trend analysis in various functional areas of health care management
• Create and generate reports through MS-Excel, MS-Access, and SQL
• Produce reports for and interface with senior management and internal and external stakeholders
• Gather and interpret business requirements and monitor data trends to proactively identify issues
• Execute data changes and update core systems as needed
• Handle multiple projects and timelines effectively
• Communicate risks and issues to the manager regularly
• Assist with training lower-level Data Analysts
• Perform other duties as assigned
• Comply with all policies and standards

Data Analyst II, Python, SQL

Investigator

• Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies
• Provide investigative support to the Special Investigations Unit related to coding and billing issues
• Identify potential overpayments and suspected health care fraud and abuse
• Verify service authorizations and documentation against claim information
• Coordinate medical necessity and level-of-care determinations with Medical Directors
• Validate services against CMS and state-specific coverage, limitations, and exclusion guidelines
• Determine code appropriateness using administrative, medical, claim, and financial records
• Develop reports of findings and recommendations
• Communicate complex audit findings in meetings and judicial hearings
• Assist SIU investigators during interviews, discussions, and negotiations
• Perform retrospective and prepayment medical-record reviews
• Investigate provider billing patterns and determine payment based on records, claim history, codes, regulations, and policies
• Prepare findings summaries and recommend next steps for providers
• Identify preventative measures and recommend policy, procedure, and provider-practice changes
• Collaborate with investigators to identify fraud, waste, and abuse using clinical and coding expertise
• Perform other assigned duties and comply with policies and standards

Clinical Investigator, Behavioral Health

Vice President

• Oversee establishment of new operational processes and operating models
• Oversee delivery of new technical capabilities and coordination across key stakeholders supporting the Duals growth strategy
• Make operational decisions and guide transformational change, including process improvements, policy updates, and operating model updates for shared services
• Partner with shared service and market leadership to establish operational strategic plans, annual objectives, KPIs, and expectations
• Serve as senior liaison between the product line, business units, corporate teams, and external stakeholders
• Partner with program management to deliver new Duals product implementations
• Lead improvement initiatives to ensure value delivery and risk mitigation
• Facilitate Duals/DSNP implementations, including SMAC requirements, MMP conversions, and DSNP RFPs
• Lead integration work for the Duals line of business
• Coordinate Duals capital program requests related to shared services operations
• Perform other duties as assigned
• Comply with all policies and standards

Vice President – Duals Initiatives

• Develop, assess, and coordinate holistic care management activities for quality, cost-effective healthcare outcomes
• Develop or assist with personalized service care plans for long-term care members
• Educate members and families/caregivers on available services and benefits
• Evaluate member needs and available resources and facilitate appropriate care plans
• Identify providers, specialists, and community resources for long-term care
• Coordinate between members/families/caregivers and care provider teams to ensure services are accessible
• Provide resource support for employment, housing, participant direction, independent living, justice, and foster care needs
• Monitor care plans, member status, and outcomes and recommend updates based on member needs
• Interact with long-term care healthcare providers and partners
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Perform on-site visits to assess member needs and collaborate with providers and resources
• Facilitate education on procedures, healthcare provider instructions, service options, referrals, and healthcare benefits
• Provide leadership feedback on opportunities to improve quality of care and service delivery
• Perform other assigned duties and comply with policies and standards

Strategy

• Support, manage, and lead strategic projects and initiatives for the department
• Support leadership in executing strategy
• Build relationships with key functional areas and provide leadership and oversight to staff
• Support Plan Administration in executing the established strategic plan and key processes
• Develop and implement Operations/Administration projects
• Plan, conduct, and direct complex Operations projects and programs
• Develop and implement action plans to improve processes
• Oversee projects and administer development and delivery of solutions
• Engage department associates and manage associate performance through communication, feedback, coaching, and development recommendations
• Coach and manage the team and direct reports
• Manage processes and projects from inception through lifecycle
• Lead and develop workflows for business processes
• Resolve internal business owner requests
• Build cross-functional relationships to drive business strategies and resolve issues
• Lead project workgroups and manage multiple projects simultaneously
• Provide leadership for strategic program initiatives and ensure financial obligations are met
• Monitor vendor, delegated, and contracted relationships and performance, including SLA oversight
• Oversee periodic executive summaries for Senior Management on performance and trends
• Perform other assigned duties
• Comply with all policies and standards

LTSS Service Care Manager

Member Advocate II

LTSS Service Care Coordinator

Senior Director, Prior Authorization Governance

Operations Auditor

Senior Manager, Quality Improvement

Utilization Review Clinician – Behavioral Health

Lead IAM Engineer

Provider Data Analyst III, SQL, Power BI

RN Readmission Manager, Payment Integrity

Data Analyst II, Python, SQL

Clinical Investigator, Behavioral Health

Vice President – Duals Initiatives

LTSS Service Care Coordinator

Manager, Strategic Initiatives