Centene Corporation

General

• Create contracts and manage the contracting process for new business opportunities
• Use the Emptoris Contract Management System to ensure new business contract deadlines are met
• Prepare contract status and metric reporting
• Identify gaps and risks in the contracting process
• Assist with workload assignment for temporary contract coordination staff
• Maintain spreadsheets and databases
• Collect, track, prepare, compile, and distribute statistical data for daily and ad hoc reports
• Interface with credentialing staff to ensure data and systems are in sync
• Provide support to contract negotiators
• Coordinate with multiple departments to complete contracting processes timely, accurately, and within established standards and guidelines
• Train temporary staff as needed
• Maintain physical and electronic file systems
• Support other departments to ensure compliance with corporate contracting standards

Contract Coordinator

Program Manager

• Plan, organize, monitor, and oversee programs using cross-functional teams to deliver defined requirements and meet business needs and strategic objectives
• Support business department initiatives promoting quality, safety, and cost-of-care opportunities
• Gather requirements and create plans and schedules
• Manage resources and facilitate project execution and deployment
• Use corporate and industry-standard tools and techniques to oversee programs according to department procedures
• Maintain detailed business process documentation, including meeting minutes, action items, issue lists, and risk management plans
• Create and monitor department deliverables to ensure adherence to quality standards, including clinical reporting documents, reference materials, and policy and procedure documentation
• Communicate program status to management and key stakeholders
• Identify resources, resolve issues, and mitigate risks
• Identify requirements, procedures, and problems to improve existing processes
• Coordinate cross-functional meetings to meet stakeholder expectations and business objectives
• Manage projects through the full project life cycle
• Provide leadership and communicate project status to stakeholders
• Negotiate with project stakeholders to secure resources, resolve issues, and mitigate risks
• For DE only: Coordinate teams to ensure HEDIS data accuracy and reporting, including investigations, auditing, and improvement opportunities
• For DE only: Collaborate with internal and external stakeholders on HEDIS and CAHPS initiatives
• For Virginia Total Care only: Oversee delivery of Consumer Directed services and collaborate with partners and health plans on system-wide solutions and quality services
• For New Hampshire Healthy Families only: Identify, secure, and maintain transportation for members; oversee the NEMT subcontractor; propose operational improvements; resolve member and provider complaints; assist with real-time service rescheduling
• Perform other duties as assigned
• Comply with all policies and standards

Program Manager II

Reimbursement Specialist

• Maintains relationships with physicians, hospitals, ancillary providers and Fidelis' internal Provider Network Management Department
• Acts as first-line contact for providers and hospitals on claims projects and other non-routine claim issues
• Oversees resolution of project issues with Adjustment and New Day Unit Supervisors
• Communicates final resolutions to providers, hospitals, business units and managers
• Assists with policy and procedure interpretation
• Researches, analyzes and resolves complex problems with claims development and finalization
• Assists with complex claim issues and large projects
• Manages projects with assigned adjusters and/or regional units for research, analysis and resolution
• Responds directly to providers with final resolutions, including root-cause documentation, corrective action plans and process improvement initiatives
• Conducts routine periodic site visits to providers, physicians and facilities
• Participates with Network Management in Joint Operating Committees
• Coordinates contract data corrections with Provider Network and Provider Data Management
• Identifies contracting opportunities based on root-cause analysis
• Interprets Health Net policies and procedures concerning claim issues, contracts and benefits
• Coordinates with Provider Network Management when unable to resolve issues with providers and internal departments
• Participates in process improvement activities and facilitates corrective actions
• Prepares monthly reports to management documenting issues, action plans and resolutions
• Researches and responds to Shared Risk Discrepancies from Participating Provider Groups
• Performs other duties as assigned
• Complies with all policies and standards

Provider Reimbursement Specialist, Fee Schedules

Pharmacist

• Manage the triage process of prior authorizations
• Supervise pharmacy technicians
• Manage departmental work flow
• Identify and develop prior authorization procedures and policies
• Coordinate with various departments to research and resolve escalated complaints and inquiries
• Monitor prior authorization processes and recommend and modify current policies and procedures
• Ensure operational integrity and compliance with associated policies and procedures
• Monitor prior authorization activities and determine appropriate staffing levels
• Oversee department performance and review reports and audit findings
• Ensure provider notification letters are communicated accurately and in a timely manner
• Oversee quality control checks and provide recommendations for improvement
• Communicate with providers and pharmacies to advise clinical outcome of prior authorization requests
• Oversee multiple pharmacy systems to track and triage prior authorization requests for Medicaid and coverage determination requests for Medicare D recipients
• Determine if a pharmacist review is required
• Perform other duties as assigned
• Comply with all policies and standards

Manager, Pharmacy Technicians

Business Analyst

• Support business initiatives through data analysis, identification of implementation barriers, and user acceptance testing of various systems
• Identify and analyze user requirements, procedures, and problems to improve existing processes
• Perform detailed analysis on multiple projects, recommend potential business solutions, and ensure successful implementations
• Identify ways to enhance performance management and operational reports related to new business implementation processes
• 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
• Diagnose problems and identify opportunities for process redesign and improvement
• Formulate and update departmental policies and procedures
• Serve as the subject matter expert on the assigned function product to ensure operational performance
• Comply with all policies and standards

Business Analyst III – Encounters, Claims, EDI, SQL

Nurse

• Review inpatient admissions and elective procedures to determine medical necessity
• Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care
• Review acuity level, resource consumption, length of stay, quality, continuity of care, and discharge planning
• Work with Medical Affairs and/or Medical Directors to discuss member care
• Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems
• Work with healthcare providers to approve medical determinations or provide recommendations
• Educate providers on utilization processes
• Provide leadership feedback on opportunities to improve level of care and medical necessity
• Review transfer and discharge plans for timely transitions between levels of care and facilities
• Collaborate with care management on member referrals
• Comply with all policies and standards
• Perform other duties as assigned

Clinical Review Nurse – Concurrent Review

Analyst

• Utilize analytical techniques, system applications, consumer research data, call center reports, ad hoc reports, system-generated reports, and other data sources to address business objectives
• Support organizational initiatives using benchmark data and insights
• Offer support for internal and external processes
• Suggest improvements based on data analysis
• Design workflows and define business requirements
• Support testing and stakeholder validation
• Serve as a cross-functional subject-matter expert
• Manage analytics applications and resources related to consumer activity
• Evaluate consumer-centric campaigns and outreach by tracking effectiveness and providing actionable recommendations
• Develop and maintain Member Experience processes and journey maps
• Aggregate key performance metrics by consumer-facing channels and analyze outcomes
• Communicate analysis results, trends, conclusions, and recommendations to stakeholders
• Partner with Consumer Experience Managers
• Deliver analytics of consumer activity across business lines
• Devise, run, and analyze A/B tests
• Provide UAT support for Member Experience initiatives
• Select appropriate methods and tools to complete assignments

Senior Consumer Experience Analyst

Care Coordinator

• Support care management activities and assigned member teams
• Ensure services are delivered by healthcare providers and partners
• Perform member outreach telephonically or through home visits
• Document care and service activities and plans
• Discuss care plans, service plans, next steps, resources, questions, and concerns with members
• Coordinate care activities with healthcare and community providers, partners, members, and caregivers
• Respond to member and provider inquiries, requests, and concerns
• Communicate with care managers, practitioners, and others to facilitate member services and continuity of care
• Support service assessments and screenings
• Maintain and distribute member records as needed
• Identify needs and make referrals to Care Managers, community-based organizations, and Disease Managers
• Provide education on available benefits and resources
• Perform other duties as assigned and comply with policies and standards

Care Coordinator II – Foster Care

• Support administrative care management activities for LTSS Waiver members
• Perform outreach to members by phone
• Answer inbound calls and serve as a frontline support contact for members and providers
• Schedule services and support care plan next steps
• Connect members with health plan and community resources
• Explain care plan procedures and protocols
• Support member onboarding and send welcome letters, correspondence, and educational materials
• Document and maintain non-clinical member records
• Provide records to providers as needed
• Make referrals addressing Social Determinants of Health needs
• Perform other duties as assigned
• Comply with all policies and standards

LTSS Care Management Support Coordinator II

Financial Planning and Analysis

• Learn about various processes and functions within the Managed Care industry
• Develop professionally by contributing to projects that support the business
• Contribute to projects across Finance, Accounting, Financial Planning & Analysis (FP&A), Internal Audit, Treasury, and Reporting
• Apply academic knowledge and learn new skills through project work
• Attend training and development presentations to enhance professional competencies
• Perform other duties as assigned
• Comply with all policies and standards

Finance and Accounting Intern, Undergraduate

Risk

• Support the development and maintenance of Risk Adjustment related programs and reporting
• Aid in working with Risk Adjustment vendors for programs within all lines of business
• Aid in the development and support of company-wide Risk Adjustment initiatives within all product lines
• Assist in vendor management related to Risk Adjustment initiatives
• Help train providers and Health Plan staff in Risk Adjustment methodologies and activities
• Research and assist in development of best practices into operations for Risk Adjustment
• Prepare operational workflows specific to each product business requirements and local market dynamics
• Prepare and participate in meetings with various committees and providers
• Perform other duties as assigned

Risk Adjustment Specialist – Clinical

• Manage the triage process of prior authorizations
• Supervise pharmacy technicians
• Manage departmental workflow
• Identify and develop prior authorization procedures and policies
• Coordinate with departments to research and resolve escalated complaints and inquiries
• Monitor prior authorization processes and modify policies and procedures
• Ensure operational integrity and compliance with policies and procedures
• Monitor prior authorization activities and determine staffing levels
• Oversee department performance and review reports and audit findings
• Ensure provider notification letters are communicated accurately and timely
• Oversee quality control checks and recommend improvements
• Communicate with providers and pharmacies about clinical outcomes of prior authorization requests
• Oversee pharmacy systems to track and triage prior authorization requests for Medicaid and Medicare Part D coverage determinations
• Determine whether pharmacist review is required

• Perform administrative care management activities, including member/provider outreach, inbound call handling, and service scheduling
• Serve as a point of contact to members, providers, and staff to resolve issues
• Provide phone outreach regarding care plan next steps, community or health plan resources, scheduling questions, concerns, and ongoing education
• Connect members with health plan and community resources to support high-quality care/service
• Apply working knowledge of assigned health plan activities and resources
• Provide front-line support for member and provider inquiries, requests, and concerns, including explaining care plan procedures and protocols
• Support member onboarding and daily administrative duties, including sending welcome letters, correspondence, and educational materials
• Document and maintain non-clinical member records in accordance with state and regulatory requirements
• Provide records to providers as needed
• Make referrals to address Social Determinants of Health needs
• Perform other duties as assigned
• Comply with all policies and standards

Care Management Support Coordinator II – LTSS Medicaid Services

Accounts Receivable

• Lead contract revenue, billing, pharmacy rebate, accounts receivable, collections, and cash application operations
• Ensure accurate revenue recognition, timely invoicing and collections, and strong financial controls
• Serve as a Finance business partner for contract implementation and revenue-related initiatives
• Ensure contract terms, billing schedules, pricing, and rebate arrangements are accurately reflected in records
• Partner with Finance and other departments on new and amended contracts and related processes
• Manage collections and monitor accounts receivable aging
• Oversee cash application and reconciliation of customer payments
• Prepare and analyze revenue, billing, AR, collections, and aging reports
• Support month-end close through account reconciliations and reporting
• Identify and resolve complex billing, contract, rebate, and AR issues
• Maintain internal controls and documentation for audit and compliance
• Lead process improvement and automation initiatives
• Develop and mentor team members
• Perform other duties as assigned

Manager, Contract Revenue & Accounts Receivable Operations

• Support administrative care management activities
• Perform outreach to members by phone
• Answer inbound calls
• Schedule services
• Serve as a point of contact for members, providers, and staff
• Resolve member and provider issues
• Document and maintain non-clinical member records according to state and regulatory requirements
• Support care plan next steps, community or health plan resources, scheduling questions, and ongoing education
• Connect members with health plan and community resources
• Apply working knowledge of assigned health plan activities and resources
• Provide front-line support for member and provider inquiries, requests, and concerns
• Explain care plan procedures and protocols
• Support member onboarding and administrative duties, including welcome letters, correspondence, and educational materials
• Make referrals to address Social Determinants of Health needs
• Comply with all policies and standards
• Perform other duties as assigned